eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Elective Abortion: Follow-up

Author: Suzanne R Trupin, MD, Clinical Professor of Obstetrics and Gynecology, University of Illinois College of Medicine-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center
Contributor Information and Disclosures

Updated: Nov 16, 2009

Follow-up

Further Inpatient Care

  • Termination of pregnancy virtually never requires inpatient treatment. If the patient has a medical condition that requires hospitalization, then the indications for hospitalization for that condition should be followed. In cases of placenta previa, the patient may have to be observed in the hospital if cervical preparation is being undertaken (laminaria insertion).
  • Patients who must have their termination performed via hysterotomy or hysterectomy are hospitalized according to the requirements of their operation.
  • Patients with a medical complication of pregnancy termination, such as a perforation, are cared for according to the treatment necessary. Initial evaluation with serial hemoglobin testing, attention to vital signs such as low blood pressure level and/or tachycardia, and repeat ultrasonography can help determine the diagnosis. A patient with temperature elevation either after laminaria insertion or immediately in the postoperative period should be evaluated for dehydration, medication reaction, infection, and sepsis. Evaluation of uterine contents can also help determine the completeness of the procedure.
  • Patients who have a fundal perforation, with an instrument that is not connected to suction, may require observation, but this is usually not necessary.
  • Patients with perforations that may be related to bowel injury may need exploratory surgery via laparoscopy (with an extremely experienced laparoscopist) or an exploratory laparotomy. Radiologic studies showing an unusual fluid collection in the pelvis, a broad-ligament hematoma, or evidence of free air increase the suspicion of a perforation. If these procedures are used, hospitalization may be required for 1-5 days to manage the usual postoperative course.
  • Antibiotic prophylaxis is recommended for any additional surgery, with broad-spectrum antibiotic coverage administered over at least 24 hours.
  • Patients who have had a medical abortion require testing to confirm completion of the process. Most providers follow up with patients 7-14 days after the procedure and use pelvic and ultrasonographic examinations to ensure that the uterus contains no fetus or sac. Home pregnancy test results are usually negative 3-4 weeks after termination of pregnancy.
  • Recent reports indicate septic death in some patients receiving a medical abortion regimen of the commonly prescribed, but technically off label, dose of 200 mg of oral mifepristone followed by 800 mcg of intravaginally placed oral misoprostol. The organisms have not been identified in all cases, but Clostridium sordellii has been identified as the source of infection in 3 of the 5 patients. The signs of infection were called atypical in all 5 patients. While the FDA has not issued guidelines regarding the use of antibiotics prophylactically in these patients, if patients have nausea, vomiting, diarrhea, or fever, impending sepsis should be suspected and appropriate antibiotic therapy should be initiated.
  • As with other medications, serious complications should be reported to FDAs MedWatch program by phone at (800) FDA-1088, by fax at (800) FDA-0178, online, or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.
  • Patients with positive pregnancy test results 3-4 weeks postabortion must be evaluated for gestational trophoblastic neoplasias as well as retained tissue. Malignant gestational trophoblastic disease is preceded by either an abortion or an ectopic pregnancy in about a quarter of the cases.

Further Outpatient Care

  • Postoperative care of a patient after surgical abortion
    • Observe patients for 30 minutes, checking for abdominal pain and unusual bleeding and observing vital signs.
    • Anti-D immunoglobulin should be administered on the day of the procedure to patients who are Rh-negative.
    • Patients selecting immediate intrauterine device (IUD) insertion, depot-medroxyprogesterone acetate (DMPA), or Implanon may begin their contraceptive on this day.
    • Postoperative appointments are usually 1-3 weeks after the procedure and are important to ensure timely involution, confirm the pregnancy termination has been completed, evaluate the patient for medical complications, offer continuing contraceptive care, and evaluate psychological status.
    • Postoperatively, patients should be given instructions to contact their providers if they have severe pain, have a fever of 100.4°F or higher, or soak through more than 4-5 pads per hour or more than 12 pads in 24 hours. The first 24 hours, a nonaspirin analgesic, such as acetaminophen, is recommended. After that time patients can switch to an NSAID, such as ibuprofen or naproxen.
    • Provide patients with emergency contact numbers and instructions regarding where to go if they have an emergency and cannot reach the provider.
    • Patients may bleed very little, if at all, if they were very early in gestation, but the most common bleeding pattern is bleeding the day of the procedure, then not much until the fifth postoperative day, when heavier cramping and clotting occurs.
    • Patients should not use tampons for 5 days and should not have intercourse until bleeding has stopped for a week or they have been cleared by their provider at their postoperative visit.
    • With antibiotic use as prophylaxis, postabortion infection rates in most population groups should be less than 1-2%. Antibiotic use for the procedure is usually limited to the day of the procedure or a 2- to 3-day course. The antibiotics used are typically broad in spectrum, and most centers use doxycycline at 100 mg bid, with erythromycin for those who are allergic. If bacterial vaginosis is discovered, then the use of Flagyl at 500 mg bid or Cleocin at 300 mg bid PO is selected. Some providers with caseloads of patients who come from far distances and are difficult to locate postoperatively may opt to administer longer antibiotic courses to cover the event of a positive chlamydia or gonorrhea test result after the patient has left the facility and either cannot or does not want to be contacted.
    • Most oral contraceptive pills can be started the day of the procedure or the following Sunday. IUDs can be inserted that day or with the next menstrual period. DMPA shots can be given that day or up to 5 days later.
  • Patients who have had their pregnancies terminated need a postoperative evaluation in 1-3 weeks. Women should be offered a contact number for any questions, and episodes of unusual pain or bleeding should be cause for an early postoperative visit.
  • Regarding uterine perforation, if the patient had a fundal perforation with no suction applied, then observation for a few hours and evaluation of Hb levels is the standard of care.
  • When evaluating for acute abdominal pain postabortion, consider acute hematometra, retained products of conception, pelvic infection, or perforation with or without bowel involvement.
  • Postoperative bleeding after a surgical abortion is different in timing, amount, and sequence to the bleeding post medical abortion. The amount and duration depends upon the gestational age of the pregnancy terminated. Patients who bleed excessively, using more than a pad per hour for 3 consecutive hours during a medical abortion, are asked to contact their providers.

Inpatient & Outpatient Medications

  • Antibiotic therapy
  • Uterotonics
  • Analgesia
  • Antiemetics
  • Antianxiolytics
  • Oral contraceptives
  • Long-term steroid contraception

Deterrence/Prevention

Effective contraception is the only reasonable strategy for abortion prevention. Since the introduction of the long-acting steroid contraceptives, abortion rates in the United States have steadily declined.

Complications

Complications of surgical abortion vary with the technique used and the gestational age of the pregnancy. In general, the more advanced the gestational age at abortion, the higher the complication rate, and the more invasive the operative procedure, the higher the complication rate.

First-trimester abortion

Complication rates are low: 0.071% for hospitalization and 0.846% for minor complications. Abortion complications requiring hospitalization include incomplete abortion (0.028%), sepsis (0.021%), uterine perforation (0.009%), vaginal bleeding (0.007%), inability to abort (0.003%), and combined pregnancy (0.002%). Minor abortion complications include infection (0.46%), repeat suction (0.18%), cervical stenosis (0.016%), cervical tear (0.01%), seizure (0.004%), and underestimate of dates (0.006%).

Manual vacuum aspiration has the following complication rates: infection, 0.7%; perforation, 0.05%; retained POC, 0.5%; and repeat aspiration, 0.5-0.25%.

Second-trimester abortion

In D&E and D&X, the skill and experience of the physician are the most important factors in maintaining a low complication rate. Complication rates are low but increase with gestational age. Abortion complications requiring hospitalization include perforation, hemorrhage, infection, retained POC, and inability to complete abortion. Overall rates of hospitalization are 0.6% at 13 weeks of gestation and 1.4% at 20-21 weeks of gestation. Coagulopathy is a rare complication in D&E, occurring in 191 of 100,000 cases.

Avoid complications by obtaining adequate cervical dilatation through using passive dilators in abortions at 14 weeks of gestation and longer and by using double placement of passive dilators at longer than 20 weeks of gestation. Have appropriate instruments available for morbidly obese patients because standard instruments may not be long enough. Match the surgeon's skill and experience to the gestational age of the pregnancy to be terminated. Choose an inpatient setting for patients with severe medical conditions, anemia, placenta praevia (or other abnormal placentation), pelvic masses or large leiomyomas, or vein problems (eg, no intravenous access). Choose to delay the operative procedure in patients with acute infection, severe vaginitis, or uncertain pregnancy dating.

  • Uterine hemorrhage
    • Hemorrhage can be caused by atony, retained products, or perforation. Hemorrhage has been defined in a variety of ways, and the need for transfusion is exceedingly rare. If uterine hemorrhage rates include hemorrhage immediately postabortion, uterine atony rates of hemorrhage are as low as 5%. Initial hemorrhage should be evaluated by ensuring complete uterine evacuation.
    • General anesthesia increases the risk of atony. Blood loss of more than 300 mL in the first trimester is considered excessive. The next steps are typically medical in nature, ie, the use of intramuscular Methergine at 0.2 mg, the use of intravenous Pitocin drips with 10-20 mIU/L running at 100-200 mL. Hemabate is also helpful. Treatment also can include uterine massage intramuscular/intracervical methylergonovine maleate (Methergine) or intramuscular 15-methyl prostaglandin (Hemabate), removal of retained products, and repair of perforation as indicated. In the past, uterine packing has been used, but this can be accomplished effectively with the intrauterine inflation of a Foley balloon. Balloons of 5 mL can be inflated with 30 mL, or 30-mL balloons can be inflated with up to almost 100 mL of sterile saline. The inflation should correlate with uterine size. Now a Bakri Balloon designed for post abortion or postpartum hemorrhage can be used.
    • Uterine artery embolization can be used if placenta accreta is encountered, but very few of these procedures have been performed and statistical success rates are impossible to evaluate. If ineffective, hysterectomy should be performed as a life-saving measure.
  • Damage to cervix: Risk is increased with previous surgery to the cervix or laceration. Damage can be associated with forceful dilation with metal dilators and may be associated with damage to cervical vessels, with hemorrhage and parametrial hematoma formation. Repair damage using a transvaginal approach or laparoscopy/ laparotomy. Prevent damage by avoiding forceful dilation. Passively dilate the cervix using passive dilators and/or prostaglandin analogues. Delay the procedure if adequate dilation is not achieved.
  • Uterine perforation
    • Perforation has been estimated to occur in 1 per 250 cases. They are usually fundal and recognized by the provider at the time of the procedure. In a study by Pridmore and Chambers of 13,907 women who underwent outpatient termination of pregnancy, the perforation rate was 0.05% and, in the second trimester, ie, procedures from 13-20 weeks, the perforation rate was 0.32%.5
    • Risk factors for perforation are previous terminations of pregnancy, lower-segment cesarean deliveries, and loop electrosurgical excision procedures of the cervix. The common denominator is thought to be scarring of the internal cervical os.
    • Fundal perforations only require observation. If the extent of the perforation cannot be determined, if the patient is medically unstable, if the suction was applied at the time of the perforation, or if bowel or fat content was obtained by forceps at the time of a perforation, surgical evaluation of the patient is necessary. The surgical evaluation may be performed by an experienced laparoscopist or by laparotomy.
    • Perforation can occur with sound, dilators, curette, suction tip, forceps, or passive dilators. Increased risk is associated with previous surgery or laceration involving the cervix, previous uterine surgery, and grand multiparity. In the first trimester, most perforations are in the body of the uterus. Perforation can be recognized when an instrument passes endlessly, heavy or persistent vaginal bleeding occurs, signs of peritoneal irritation appear, or fat or other tissue appears in the specimen. If perforation is made with the sound or dilator, stop the procedure and observe the patient for a minimum of 1 hour. Antibiotic prophylaxis and ultrasonography are options. Reschedule the procedure to be performed in 2-3 weeks. If perforation occurs with suction tip or curette, stop the procedure. Options include observation if the patient is stable and the abortion is complete, laparoscopy if hemorrhage is suspected or the abortion is incomplete, and laparotomy if the patient is unstable.
  • Retained products of conception
    • Evaluation of the obtained products of conception at the time of abortion and postabortion uterine scanning have reduced the retained products of conception rate to less than 1% of cases. In one series reported by Hakim, Tovell, and Burnhill of 170,000 cases, only 0.5% incidence occurred in the first trimester.6 In cases of second-trimester abortions, retained tissue rates are even lower, with rates of 0.2% according to Peterson and 0.5% according to Kafrissen et al.7
    • Cases of delayed bleeding, even after a normal cycle, have been reported. Dilatation and curettage or hysteroscopy are necessary if bleeding is brisker or if the amount of tissue is determined by sonographic evaluation to warrant more extensive procedures. Endometrial color-flow evaluation can be helpful in determining if tissue is retained.
  • Endometritis and pelvic inflammatory disease
    • Infections postabortion are rare, occurring in fewer than 1% of cases. These are usually due to preexisting infections, such as bacterial vaginosis, cervicitis or salpingitis, or a failure of antibiotic prophylaxis.
    • Fever greater than 102°F (39°C) within 72 hours of the abortion should be considered septic abortion due to retained products. Treatment requires reaspiration followed by intravenous antibiotics (cefoxitin, clindamycin, chloramphenicol, cephalosporin with ampicillin, or penicillinase-resistant penicillin). Fever less than 102°F (39°C) should be treated with reaspiration and oral antibiotics (doxycycline 100 mg bid for 10 d).
    • The usual criteria should be used for the diagnosis of pelvic inflammatory disease (PID). A thorough discussion of PID and the criteria for diagnosis can be found at Pelvic Inflammatory Disease: Guidelines for Prevention and Management.
  • Fatal toxic shock: Rapidly progressing toxic shock due to the endotoxins produced by Clostridia species bacteria has been reported 7 times (for a rate of 1 per 750,000).
  • Coexistent ectopic pregnancy
    • Residual positive hCG titers are not uncommon, and clinicians need to be vigilant in their evaluation of persistent positive pregnancy test results to avoid missing an ectopic pregnancy.
    • Pelvic ultrasonography is the most helpful tool. The presence of significant tenderness during the postoperative examination, a history of continued pain, and the elevation or plateau of hCG titers should raise concern. Coexistent intrauterine and extrauterine pregnancies are observed only in extremely rare cases.
  • Asherman syndrome
    • Postabortion uterine synechiae (or adhesions) that can obliterate part or all of the endometrial cavity have been reported. This is thought to be more likely secondary to endometritis than the instrumentation of the uterus, but sharp curetting after the abortion procedure should be avoided to avoid denuding the basal layer of the endometrium.
    • The diagnosis is made based on hysteroscopy or hysterosalpingogram findings in a patient who presents with postabortion amenorrhea.
  • Delayed sequelae
  • Abortion-related hemorrhage due to retained tissue can occur up to several weeks after the procedure. In general, blood loss in excess of that of a normal menstrual period is considered significant and should prompt reaspiration.
  • Few long-term sequelae of abortions have been documented. Both studies of first trimester surgical and medical abortion found that risks of ectopic pregnancies, spontaneous abortions, and preterm birth or low birthweight infants in future pregnancies were not increased. Although a syndrome of posttraumatic stress has been reported, the literature has not been able to separate the stressors of the patient's social situation that lead to the abortion from the abortion procedure itself.
  • Although initial studies indicated a greater risk of breast cancer with elective termination than with term birth, a prospective cohort study indicates that no link exists between induced abortion and breast cancer. A prospective study (the Nurses' Health Study II) examined the association between induced and spontaneous abortion and the incidence of breast cancer. Most of the early data has been refuted. In the Iowa Women's Health Study, women aged 55-64 years had their health records from the state linked with the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER). Only 1.8% of the women in this study reported induced abortion. This rate is lower than the rate typically reported in this age group; however, the relative risk of breast cancer for those with prior induced abortion was 1.1%. These results must be reevaluated over time.
  • One recent article reported a slightly greater incidence of adenomyosis postabortion. A study by Zhou et al of 15,727 women who had induced abortions compared with 46,026 women who did not have induced abortions showed an increased risk in preterm and postterm pregnancy after induced abortion.8 Another study by Hendricks et al showed that both induced abortion and prior cesarean delivery increased the risk of placenta previa.9 The risk of placenta previa developing in women with 3 prior cesarean deliveries was increased 22.4 times. The risk of placenta previa developing in women having 2 or more previous abortions was increased 2.1 times.
  • In another study by Eras et al, abortion was suggested as a protective factor against the development of preeclampsia in a subsequent pregnancy in women with no prior deliveries.10
  • Psychologic consequences of abortion
    • Generally, the psychological health of the abortion patient parallels her psychologic health prior to seeking an abortion. If the woman needed to have the abortion in secrecy, then long-term psychologic sequelae, such as intrusive thoughts, are more common.
    • Many studies have actually demonstrated improved psychological well-being after abortion. For the studies that have shown this, the improvement in psychological health is suggested to be more reflective of the patient dealing with the social issues that led her to select abortion.
    • Sometimes, confusion over normal emotions, such as sadness and grief versus psychological illnesses (eg, depression), seems to occur. The most common feeling experienced after an abortion is that of relief and confidence in the decision. Few women may experience feelings of grief and guilt postabortion, and these feelings usually pass within days to weeks in most cases and do not lead to psychological sequelae. One study demonstrated that the risk for serious psychiatric illness postabortion was 1%, whereas with live birth it was 10%. Few studies on these data exist, partly because studies performed earlier gave no indication for psychiatric sequelae so no new findings have been researched. Considering that more than 1.5 million abortions are performed in the United States each year, if an epidemic of psychiatric sequelae due to the procedure occurred, it would be observed by now.
    • Many confounding factors are involved in a women's emotional status during the time of her abortion. Relationships, religion, age, social support, and previous psychological stability all play a part.
    • An entirely new set of circumstances and feelings exist in cases of rape and incest. These are often psychologically complex situations and unique to each case.
    • Providers can help women through abortions by presenting options and explaining the procedures. Counseling with a trained professional occurs before the abortion. This is a good time to identify factors that might lead to a patient having troubling feelings after the abortion. Some factors are low self-esteem, preexisting or past psychological illness, lack of emotional support, and past childhood sexual abuse. The counselor can then confront these issues before the procedure and help the patient assess specific needs and improve coping strategies.
  • Complications associated with instillation techniques are as follows:
    • Hemorrhage requiring transfusion (0.32-1.72%)
    • Infection
    • Incomplete abortion
    • Cervical laceration
    • Hypernatremia and sodium load (saline)
    • Muscle necrosis (myometrial injection of saline or urea)
    • Adverse gastrointestinal effects
    • Unintended surgery (0.04-0.08 cases per 100 instillations)
    • Disseminated intravascular coagulopathy (saline, 658 cases per 100,000 instillations)

Urea instillation abortions are reported to be safer than saline abortions. Prostaglandin-induced second trimester abortions are safer than saline abortions and have a lower induction-to-completion time.

Of all methods of second trimester abortion, the safest procedure (using mortality surveillance data) is dilation and extraction. Labor induction with prostaglandins and passive dilators has a higher risk than dilation and extraction due to the risk of retained placenta. Intermediate risk of mortality occurs with instillation procedures. The highest mortality rates for second-trimester abortions are associated with major surgical procedures (ie, hysterotomy, hysterectomy).

Selective reduction procedures are not included in the statistics for second-trimester abortions. For the rare condition of monochorionic twins, selective reduction cord occlusion techniques are reported by Challis et al to have premature rupture of membranes in up to 30% of cases.11 The more common method of intracardiac injection techniques for selective reduction is associated with premature rupture of membranes in 13% of triplet pregnancies reduced to twins and in 19.3% of quadruplets reduced to twins. The risk of miscarriage in a pregnancy undergoing selective reduction is inversely proportional to the number of fetuses in the initial pregnancy (ie, quintuplet, 24.8%; triplet, 8.3%).

Prognosis

Fertility is not impaired. Prognosis is excellent.

Patient Education

  • Give patients information about abortion and postabortion care.
  • Educate patients about birth control options, and discuss when to start birth control postabortion.
  • Because most terminations of pregnancies in the United States are performed on unintended pregnancies, counseling regarding fertility and contraceptive management are mandatory. In 83% of women, ovulation occurs in the first menstrual cycle postabortion. In first-trimester abortions, contraception should be initiated immediately postoperatively. Intrauterine devices (IUDs) can be safely inserted at the time of the abortion procedure.
  • For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Procedures Center. Also, see eMedicine's patient education articles Abortion, Miscarriage, and Dilation and Curettage (D&C).

Miscellaneous

Medicolegal Pitfalls

  • Abortion rights in the United States
    • The abortion ethics debate has kept termination of pregnancy in the courts and media since the landmark decision in Roe v Wade. The original ruling was fairly straightforward, legally confirming a woman's right to a private medical decision when selecting a medical procedure.
    • As the debate has raged and the medical issues have become more complex, rulings in the courts and in the legislatures have extended beyond this simplistic question to restrictions on gestational age, viability determinations, spousal and parental consents, enforced waiting periods, enforced language in consents, enforcement of provider qualifications, the right to use fetal tissue for research or medical treatments, the rights of providers and patients to be shielded from overt protest, and, finally, on access to contraception.
    • In a typical year, hundreds of laws and rulings are proposed, some even specifically criminalize performing abortions. Some laws are passed, yet they are not enforceable because they are enjoined by a court order. Current laws are difficult to follow, but a summary from The Alan Guttmacher Institute can be found at State Policies in Brief.
    • Prior to the 1960s, an estimated 9 of 10 out-of-wedlock pregnancies were electively aborted. These procedures were performed in a variety of medical and lay settings, and almost 20% of all pregnancy-related complications were due to illegal abortions.
    • Individuals who perform terminations of pregnancies are bound by their state's reporting laws. A complete listing of current reporting requirements is available through the Centers for Disease Control and Prevention.
  • Roe v Wade
    • An important early decision by the US Supreme Court constitutionally establishing a woman's right to privacy was Griswold v Connecticut in 1965.
    • In the early 1970s, political support was overwhelmingly in support of legalized abortion, and activists for abortion rights specifically sought a plaintiff so that a legal challenge to abortions could be argued in court. The plaintiff, Norma McCorvey, was the "Jane Roe" for whom the decision is named. The US Centers for Disease Control and Prevention define an induced abortion as "a procedure intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age."
  • Eroding abortion rights
    • Although the fundamental right to have an abortion has remained intact by basic statute, poor women have had their rights eroded by the Hyde amendment in 1976 that prohibited the use of federal funds for abortions except in the case of maternal life endangerment. This, in conjunction with a rise in the takeover of hospitals in some regions by religious organizations opposed to abortion and contraception, has restricted access to abortion. Almost one third of publicly funded recipients are prevented from having a termination by lack of access to care. Public controversy has raged on the specific question of whether individuals or institutions should be allowed to refuse medical care. Although 45 states have enacted laws allowing such refusal, only 5 have also enacted laws that require the provider to notify patients of their refusal. These provisions extend to contraceptive and sterilization services.
    • The fetus can survive extrauterine life at term and with life support in the mid second trimester. No definitive point exists at which the fetus cannot survive, nor has a point at which viability exists been agreed upon medically, legislatively, or religiously. Fetuses are generally considered viable after 27 weeks of pregnancy and not viable at less than 20 weeks of pregnancy.
    • In a 1989 decision called Webster v Reproductive Health Services, the Court upheld the state's right to determine viability testing after 20 weeks of gestation, and in the legal preamble, the wording states that life begins at conception. Other laws cover similar legal concepts. In Planned Parenthood v Casey, some fetuses were recognized to never attain viability (anencephalics), and in Colautti v Franklin, the provisions are even broader, recognizing that clinician judgment may be the most important.
    • For a listing of abortion-related historical facts, see the Hope Clinic for Women, History of Abortion.
  • Late-term abortions
    • Although only 2% of the population verbalizes opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, another divisive factor has crept into the debate. Abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.
    • By 1998, 28 states had passed bans on this procedure, referred to in the lay press as a partial-birth abortion, which is the medical procedure intact dilatation and extraction. The descriptive language in the US Criminal Code, if passed, would make it illegal to "deliberately and intentionally deliver into the vagina a living fetus, or a substantial portion thereof, for the purpose of performing a procedure that is known will kill the fetus and kills the fetus."
    • President Clinton twice vetoed the federal Partial-Birth Abortion Ban Act on the grounds that the language is unconstitutionally vague and provides no clear direction on how to apply the law. Oddly, clinicians have been successfully sued for failure to refer patients for late-term abortions in cases of fetal abnormalities. The rationale for continued need for late abortions has been argued thoroughly by David Grimes in his article "The Continuing Need for Late Abortions."
    • Since the time of Roe v Wade, clinicians, patients, and the US Supreme Court have repeatedly reaffirmed that the determination about medical need, the choice of a procedure, and viability is best left as a medical decision, not one for the legislature.
  • Parental consent
    • Most young adolescents have parental or family involvement in their decision to have an abortion. Adolescents who are older, especially those living independently, often do not. In spite of ample scientific evidence that many teens seek parental involvement and widespread legal concern that individuals who do not seek parental involvement may be at risk physically or emotionally, a barrage of legislation mandates that all minors seek parental consents or that the parents be notified in advance of a minor child having an abortion.
    • The laws that have enabled this to occur legally are backed by the US Supreme Court. By 1999, 38 states had such laws, and 29 states enforce their laws. Currently, only Connecticut, Maine, and the District of Columbia have laws that affirm the rights of a minor to seek her own abortion. For a summary of laws as of September of 2000, see Minors' Right to Consent to Health Care and to Make Other Important Decisions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents who may travel hundreds of miles to seek an abortion.
    • Patient rights bills have been developed by a variety of groups, including the Consumers' Bill of Rights and Responsibilities that has been developed by a presidential task force. These bills specifically state that patients have a right to access knowledge and that providers have a right to discuss care they think is medically appropriate regardless of the source of that care.
  • Mandatory waiting periods
    • Mandatory waiting periods mandate by law that the woman seeking to terminate a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives.
    • In spite of the fact that these laws typically only mandate a short 24-hour waiting period, they have the effect of increasing the percentage of second-trimester abortions in states with these laws.
  • State-developed counseling materials: A variety of state-developed counseling materials have come into use across the United States. For the most part they have been pushed through by antiabortion activists. In Minnesota, specific wording refers to studies that suggest a link between breast cancer and abortion, although a 2003 National Cancer Institute census report found no such link. Other states have developed unfounded and unreferenced materials on topics such as fetal pain, the psychological effects of abortion, and coercion.

Special Concerns

  • The abortion debate
    • Advances in neonatal medicine leading to improved fetal survival very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on the beginning of life.
    • Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments has kept the debate both vocal and contentious. These potential therapies may be indicated in the treatment of diabetes, Parkinson disease, kidney disease, and cartilage diseases, among others.
    • Current national regulations prohibit most fetal tissue research, but the National Institute of Health revealed late in the year 2000 that it would allow stem cell research. In June 2002, however, President Bush enacted a law restricting stem cell research to only preexisting cell lines and embryos "left over" from in vitro fertilization procedures.
    • Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface.
  • Provider issues
    • Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (eg, family practitioners, nurses) can be taught to perform abortions safely. Physicians are generally receptive to the concept of legal abortions being available in the United States. Epidemiologic research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.
    • Keeping abortions safe, legal, and rare are the goals of abortion providers. For information from physicians regarding these goals, see Physicians for Reproductive Choice and Health.
    • As providers have decreased in number, women are traveling farther to obtain abortions, presenting later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.
    • Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.
 


More on Elective Abortion

Overview: Elective Abortion
Differential Diagnoses & Workup: Elective Abortion
Treatment & Medication: Elective Abortion
Follow-up: Elective Abortion
References
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References

  1. Kahn JG, Becker BJ, MacIsaa L, et al. The efficacy of medical abortion: a meta-analysis. Contraception. Jan 2000;61(1):29-40. [Medline].

  2. Koenig JD, Tapias MP, Hoff T, Stewart FH. Are US health professionals likely to prescribe mifepristone or methotrexate?. J Am Med Womens Assoc. 2000;55(3 Suppl):155-60. [Medline].

  3. [Best Evidence] Dickinson JE, Doherty DA. Optimization of third-stage management after second-trimester medical pregnancy termination. Am J Obstet Gynecol. Sep 2009;201(3):303.e1-7. [Medline].

  4. Perry KG Jr, Rinehart BK, Terrone DA, Martin RW, May WL, Roberts WE. Second-trimester uterine evacuation: A comparison of intra-amniotic (15S)-15-methyl-prostaglandin F2alpha and intravaginal misoprostol. Am J Obstet Gynecol. Nov 1999;181(5 Pt 1):1057-61. [Medline].

  5. Pridmore BR, Chambers DG. Uterine perforation during surgical abortion: a review of diagnosis, management and prevention. Aust N Z J Obstet Gynaecol. Aug 1999;39(3):349-53. [Medline].

  6. Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol. Jul 1990;76(1):129-35. [Medline].

  7. Kafrissen ME, Barke MW, Workman P, Schulz KF, Grimes DA. Coagulopathy and induced abortion methods: rates and relative risks. Am J Obstet Gynecol. Oct 1 1983;147(3):344-5. [Medline].

  8. Zhou W, Sorensen HT, Olsen J. Induced abortion and subsequent pregnancy duration. Obstet Gynecol. Dec 1999;94(6):948-53. [Medline].

  9. Hendricks MS, Chow YH, Bhagavath B, Singh K. Previous cesarean section and abortion as risk factors for developing placenta previa. J Obstet Gynaecol Res. Apr 1999;25(2):137-42. [Medline].

  10. Eras JL, Saftlas AF, Triche E, Hsu CD, Risch HA, Bracken MB. Abortion and its effect on risk of preeclampsia and transient hypertension. Epidemiology. Jan 2000;11(1):36-43. [Medline].

  11. Challis D, Gratacos E, Deprest JA. Cord occlusion techniques for selective termination in monochorionic twins. J Perinat Med. 1999;27(5):327-38. [Medline].

  12. Acharya PS, Gluckman SJ. Bacteremia following placement of intracervical laminaria tents. Clin Infect Dis. Sep 1999;29(3):695-7. [Medline].

  13. ACOG. ACOG practice bulletin. Clinical management guidelines of obstetrician-gynecologists. Number 67, October 2005. Medical management of abortion. Obstet Gynecol. Oct 2005;106(4):871-82. [Medline].

  14. ACOG. American College of Obstetricians and Gynecologists. Methods of Midtrimester Abortion. ACOG Technical Bulletin. 1987;109:602-05.

  15. ACOG Compendium of Selected Publications. American College of Obstetricians and Gynecologists. Abortion Policy. 2005;865-867.

  16. Aiyer AN, Ruiz G, Steinman A, Ho GY. Influence of physician attitudes on willingness to perform abortion. Obstet Gynecol. Apr 1999;93(4):576-80. [Medline].

  17. Ashok PW, Templeton A. Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases. Br J Obstet Gynaecol. Jul 1999;106(7):706-10. [Medline].

  18. Baird DT. Mode of action of medical methods of abortion. J Am Med Womens Assoc. 2000;55(3 Suppl):121-6. [Medline].

  19. Ballagh SA, Harris HA, Demasio K. Is curettage needed for uncomplicated incomplete spontaneous abortion?. Am J Obstet Gynecol. Nov 1998;179(5):1279-82. [Medline].

  20. Bartholomew LL, Grimes DA. The alleged association between induced abortion and risk of breast cancer: biology or bias?. Obstet Gynecol Surv. Nov 1998;53(11):708-14. [Medline].

  21. Begley AM. Preparation for practice in the new millennium: a discussion of the moral implications of multifetal pregnancy reduction. Nurs Ethics. Mar 2000;7(2):99-112. [Medline].

  22. Berer M. Making abortions safe: a matter of good public health policy and practice. Bull World Health Organ. 2000;78(5):580-92. [Medline].

  23. Bernick BA, Ufberg DD, Nemiroff R, Donnenfeld A, Tolosa JE. Success rate of cytogenetic analysis at the time of second-trimester dilation and evacuation. Am J Obstet Gynecol. Oct 1998;179(4):957-61. [Medline].

  24. Bernstein PS, Rosenfield A. Abortion and maternal health. Int J Gynaecol Obstet. Dec 1998;63 Suppl 1:S115-22. [Medline].

  25. Blanchard K, Winikoff B, Ellertson C. Misoprostol used alone for the termination of early pregnancy. A review of the evidence. Contraception. Apr 1999;59(4):209-17. [Medline].

  26. Borgatta L, Burnhill M, Haskell S, Nichols M, Leonhardt K. Instituting medical abortion services: changes in outcome and acceptability related to provider experience. J Am Med Womens Assoc. 2000;55(3 Suppl):173-6. [Medline].

  27. Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol. Sep 2001;185(3):530-6. [Medline].

  28. Borgmann CE, Jones BS. Legal issues in the provision of medical abortion. Am J Obstet Gynecol. Aug 2000;183(2 Suppl):S84-94. [Medline].

  29. Bourguignon A, Briscoe B, Nemzer L. Genetic abortion: considerations for patient care. J Perinat Neonatal Nurs. Sep 1999;13(2):47-58. [Medline].

  30. Breitbart V, Repass DC. The counseling component of medical abortion. J Am Med Womens Assoc. 2000;55(3 Suppl):164-6. [Medline].

  31. Cakir L, Dilbaz B, Caliskan E, Dede FS, Dilbaz S, Haberal A. Comparison of oral and vaginal misoprostol for cervical ripening before manual vacuum aspiration of first trimester pregnancy under local anesthesia: a randomized placebo-controlled study. Contraception. May 2005;71(5):337-42. [Medline].

  32. Castadot RG. Pregnancy termination: techniques, risks, and complications and their management. Fertil Steril. Jan 1986;45(1):5-17. [Medline].

  33. Cates W, Ellertson C. Contraceptive Technology. In: Hatcher RA, Trussel J, Stewart F, et al. Abortion. 17th ed. New York, NY: Ardent Media; 1998:682-697.

  34. Chapman SJ, Crispens M, Owen J, Savage K. Complications of midtrimester pregnancy termination: the effect of prior cesarean delivery. Am J Obstet Gynecol. Oct 1996;175(4 Pt 1):889-92. [Medline].

  35. Chasen ST, Kalish RB, Gupta M, Kaufman JE, Rashbaum WK, Chervenak FA. Dilation and evacuation at >or=20 weeks: comparison of operative techniques. Am J Obstet Gynecol. May 2004;190(5):1180-3. [Medline].

  36. Christin-Maitre S, Bouchard P, Spitz IM. Medical termination of pregnancy. N Engl J Med. Mar 30 2000;342(13):946-56. [Medline].

  37. Chung TK, Lee DT, Cheung LP, Haines CJ, Chang AM. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertil Steril. Jun 1999;71(6):1054-9. [Medline].

  38. Clark S, Ellertson C, Winikoff B. Is medical abortion acceptable to all American women: the impact of sociodemographic characteristics on the acceptability of mifepristone-misoprostol abortion. J Am Med Womens Assoc. 2000;55(3 Suppl):177-82. [Medline].

  39. Cohen AL, Bhatnagar J, Reagan S, et al. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol. Nov 2007;110(5):1027-33. [Medline].

  40. Cole DS, Bruck LR. Anaphylaxis after laminaria insertion. Obstet Gynecol. Jun 2000;95(6 Pt 2):1025. [Medline].

  41. Cook RJ, Dickens BM. Human rights and abortion laws. Int J Gynaecol Obstet. Apr 1999;65(1):81-7. [Medline].

  42. Coyaji K. Early medical abortion in India: three studies and their implications for abortion services. J Am Med Womens Assoc. 2000;55(3 Suppl):191-4. [Medline].

  43. Creinin MD. Conception rates after abortion with methotrexate and misoprostol. Int J Gynaecol Obstet. May 1999;65(2):183-8. [Medline].

  44. Creinin MD. Medical abortion regimens: historical context and overview. Am J Obstet Gynecol. Aug 2000;183(2 Suppl):S3-9. [Medline].

  45. Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA. A randomized comparison of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. Obstet Gynecol. May 2004;103(5 Pt 1):851-9. [Medline].

  46. Creinin MD, Jerald H. Success rates and estimation of gestational age for medical abortion vary with transvaginal ultrasonographic criteria. Am J Obstet Gynecol. Jan 1999;180(1 Pt 1):35-41. [Medline].

  47. Creinin MD, Pymar HC. Medical abortion alternatives to mifepristone. J Am Med Womens Assoc. 2000;55(3 Suppl):127-32, 150. [Medline].

  48. Creinin MD, Spitz IM. Use of various ultrasonographic criteria to evaluate the efficacy of mifepristone and misoprostol for medical abortion. Am J Obstet Gynecol. Dec 1999;181(6):1419-24. [Medline].

  49. Creinin MD, Wiebe E, Gold M. Methotrexate and misoprostol for early abortion in adolescent women. J Pediatr Adolesc Gynecol. May 1999;12(2):71-7. [Medline].

  50. Cunningham GF, MacDonald PC, Gant NF. Abortion. In: Williams Obstetrics. 19th ed. 1993:661-90.

  51. Daling JR, Emanuel I. Induced abortion and subsequent outcome of pregnancy. A matched cohort study. Lancet. Jul 26 1975;2(7926):170-3. [Medline].

  52. Davis A, Westhoff C, De Nonno L. Bleeding patterns after early abortion with mifepristone and misoprostol or manual vacuum aspiration. J Am Med Womens Assoc. 2000;55(3 Suppl):141-4. [Medline].

  53. Dean G, Cardenas L, Darney P, Goldberg A. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception. Mar 2003;67(3):201-6. [Medline].

  54. Delfs E, Katayama KP. Surgical Management of Reproductive Failure and Abortion. Te Linde's Operative Gynecology. Fifth Edition. 1977:429-451.

  55. Dobie SA, Hart LG, Glusker A, Madigan D, Larson EH, Rosenblatt RA. Abortion services in rural Washington State, 1983-1984 to 1993-1994: availability and outcomes. Fam Plann Perspect. Sep-Oct 1999;31(5):241-5. [Medline].

  56. Drey EA, Thomas LJ, Benowitz NL, Goldschlager N, Darney PD. Safety of intra-amniotic digoxin administration before late second-trimester abortion by dilation and evacuation. Am J Obstet Gynecol. May 2000;182(5):1063-6. [Medline].

  57. Edmondson AS, Cooke EM. The development and assessment of a bacteriocin typing method for Klebsiella. J Hyg (Lond). Apr 1979;82(2):207-23. [Medline].

  58. Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol. Jul 1999;94(1):139-41. [Medline].

  59. Elul B, Ellertson C, Winikoff B, Coyaji K. Side effects of mifepristone-misoprostol abortion versus surgical abortion. Data from a trial in China, Cuba, and India. Contraception. Feb 1999;59(2):107-14. [Medline].

  60. Elul B, Pearlman E, Sorhaindo A, Simonds W, Westhoff C. In-depth interviews with medical abortion clients: thoughts on the method and home administration of misoprostol. J Am Med Womens Assoc. 2000;55(3 Suppl):169-72. [Medline].

  61. Epner JE, Jonas HS, Seckinger DL. Late-term abortion. JAMA. Aug 26 1998;280(8):724-9. [Medline].

  62. Evans MI, Goldberg JD, Horenstein J, et al. Selective termination for structural, chromosomal, and mendelian anomalies: international experience. Am J Obstet Gynecol. Oct 1999;181(4):893-7. [Medline].

  63. Fitzpatrick KM, Wilson M. Exposure to violence and posttraumatic stress symptomatology among abortion clinic workers. J Trauma Stress. Apr 1999;12(2):227-42. [Medline].

  64. Fong YF, Singh K, Prasad RN. Severe hyperthermia following use of vaginal misoprostol for pre-operative cervical priming. Int J Gynaecol Obstet. Jan 1999;64(1):73-4. [Medline].

  65. Frank PI, McNamee R, Hannaford PC, Kay CR, Hirsch S. The effect of induced abortion on subsequent pregnancy outcome. Br J Obstet Gynaecol. Oct 1991;98(10):1015-24. [Medline].

  66. Geva E, Fait G, Yovel I, et al. Second-trimester multifetal pregnancy reduction facilitates prenatal diagnosis before the procedure. Fertil Steril. Mar 2000;73(3):505-8. [Medline].

  67. Gouk EV, Lincoln K, Khair A, Haslock J, Knight J, Cruickshank DJ. Medical termination of pregnancy at 63 to 83 days gestation. Br J Obstet Gynaecol. Jun 1999;106(6):535-9. [Medline].

  68. Grimes D, Schulz K, Stanwood N. Immediate post-abortal insertion of intrauterine devices. Cochrane Database Syst Rev. 2000;CD001777. [Medline].

  69. Grimes DA. A 26-year-old woman seeking an abortion. JAMA. Sep 22-29 1999;282(12):1169-75. [Medline].

  70. Grimes DA. The continuing need for late abortions. JAMA. Aug 26 1998;280(8):747-50. [Medline].

  71. Grimes DA. Unsafe abortion: the silent scourge. Br Med Bull. 2003;67:99-113. [Medline].

  72. Grimes DA, Schulz KF. Morbidity and mortality from second-trimester abortions. J Reprod Med. Jul 1985;30(7):505-14. [Medline].

  73. Hamoda H, Ashok PW, Flett GM, Templeton A. A randomised controlled trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion up to 13 weeks of gestation. BJOG. Aug 2005;112(8):1102-8. [Medline].

  74. Hamoda H, Ashok PW, Flett GM, Templeton A. Medical abortion at 64 to 91 days of gestation: a review of 483 consecutive cases. Am J Obstet Gynecol. May 2003;188(5):1315-9. [Medline].

  75. Hamoda H, Ashok PW, Flett GM, Templeton A. Medical abortion at 9-13 weeks' gestation: a review of 1076 consecutive cases. Contraception. May 2005;71(5):327-32. [Medline].

  76. Heath V, Chadwick V, Cooke I, Manek S, MacKenzie IZ. Should tissue from pregnancy termination and uterine evacuation routinely be examined histologically?. BJOG. Jun 2000;107(6):727-30. [Medline].

  77. Hellberg D, Mogilevkina I, Mardh PA. Sexually transmitted diseases and gynecologic symptoms and signs in women with a history of induced abortion. Sex Transm Dis. Apr 1999;26(4):197-200. [Medline].

  78. Henshaw SK. Abortion incidence and services in the United States, 1995-1996. Fam Plann Perspect. Nov-Dec 1998;30(6):263-70, 287. [Medline].

  79. Hern WM. Second-trimester surgical abortions. In: Sciarra JJ. Gynecology and Obstetrics. Philadelphia, PA: JB Lippincott Co; 2002.

  80. Isley MM, Blumenthal P. Medical Abortion What's Old, what's new?. Contemporary OB GYN. Apr 15 2008;30-38.

  81. Jackson RA, Teplin VL, Drey EA, Thomas LJ, Darney PD. Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial. Obstet Gynecol. Mar 2001;97(3):471-6. [Medline].

  82. Jain JK, Kuo J, Mishell DR Jr. A comparison of two dosing regimens of intravaginal misoprostol for second-trimester pregnancy termination. Obstet Gynecol. Apr 1999;93(4):571-5. [Medline].

  83. Jain JK, Meckstroth KR, Mishell DR Jr. Early pregnancy termination with intravaginally administered sodium chloride solution-moistened misoprostol tablets: historical comparison with mifepristone and oral misoprostol. Am J Obstet Gynecol. Dec 1999;181(6):1386-91. [Medline].

  84. Jain JK, Meckstroth KR, Park M, Mishell DR Jr. A comparison of tamoxifen and misoprostol to misoprostol alone for early pregnancy termination. Contraception. Dec 1999;60(6):353-6. [Medline].

  85. Jensen JT, Harvey SM, Beckman LJ. Acceptability of suction curettage and mifepristone abortion in the United States: a prospective comparison study. Am J Obstet Gynecol. Jun 2000;182(6):1292-9. [Medline].

  86. Jensen MP, Miller L, Fisher LD. Assessment of pain during medical procedures: a comparison of three scales. Clin J Pain. Dec 1998;14(4):343-9. [Medline].

  87. Jermy K, Oyelese O, Bourne T. Uterine anomalies and failed surgical termination of pregnancy: the role of routine preoperative transvaginal sonography. Ultrasound Obstet Gynecol. Dec 1999;14(6):431-3. [Medline].

  88. Jones BS, Heller S. Providing medical abortion: legal issues of relevance to providers. J Am Med Womens Assoc. 2000;55(3 Suppl):145-50. [Medline].

  89. Joyce T, Kaestner R. The impact of Mississippi's mandatory delay law on the timing of abortion. Fam Plann Perspect. Jan-Feb 2000;32(1):4-13. [Medline].

  90. Kafrissen ME, Grimes DA, Hogue CJ, Sacks JJ. Cluster of abortion deaths at a single facility. Obstet Gynecol. Sep 1986;68(3):387-9. [Medline].

  91. Kalish RB, Chasen ST, Rosenzweig LB, Rashbaum WK, Chervenak FA. Impact of midtrimester dilation and evacuation on subsequent pregnancy outcome. Am J Obstet Gynecol. Oct 2002;187(4):882-5. [Medline].

  92. Keder LM. Best practices in surgical abortion. Am J Obstet Gynecol. Aug 2003;189(2):418-22. [Medline].

  93. Kero A, Hogberg U, Lalos A. Wellbeing and mental growth-long-term effects of legal abortion. Soc Sci Med. Jun 2004;58(12):2559-69. [Medline].

  94. Kero A. Wellbeing and mental growth - long term effects of legal abortion.

  95. Kjems E, Krag C. Melanoma and pregnancy. A review. Acta Oncol. 1993;32(4):371-8. [Medline].

  96. Koonin LM. Abortion reporting in the era of medical procedures: why is it important?. J Am Med Womens Assoc. 2000;55(3 Suppl):203-4. [Medline].

  97. Kruse B. Advanced practice clinicians and medical abortion: increasing access to care. J Am Med Womens Assoc. 2000;55(3 Suppl):167-8. [Medline].

  98. Kruse B, Poppema S, Creinin MD, Paul M. Management of side effects and complications in medical abortion. Am J Obstet Gynecol. Aug 2000;183(2 Suppl):S65-75. [Medline].

  99. Lahteenmaki P, Luukkainen T. Return of ovarian function after abortion. Clin Endocrinol (Oxf). Feb 1978;8(2):123-32. [Medline].

  100. Larsson PG, Platz-Christensen JJ, Dalaker K, et al. Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study. Acta Obstet Gynecol Scand. May 2000;79(5):390-6. [Medline].

  101. Lazovich D, Thompson JA, Mink PJ, Sellers TA, Anderson KE. Induced abortion and breast cancer risk. Epidemiology. Jan 2000;11(1):76-80. [Medline].

  102. Levgur M, Abadi MA, Tucker A. Adenomyosis: symptoms, histology, and pregnancy terminations. Obstet Gynecol. May 2000;95(5):688-91. [Medline].

  103. Lichtenberg ES, Shott S. A randomized clinical trial of prophylaxis for vacuum abortion: 3 versus 7 days of doxycycline. Obstet Gynecol. Apr 2003;101(4):726-31. [Medline].

  104. Linn S, Schoenbaum SC, Monson RR, Rosner B, Stubblefield PG, Ryan KJ. The relationship between induced abortion and outcome of subsequent pregnancies. Am J Obstet Gynecol. May 15 1983;146(2):136-40. [Medline].

  105. Macisaac L, Darney P. Early surgical abortion: an alternative to and backup for medical abortion. Am J Obstet Gynecol. Aug 2000;183(2 Suppl):S76-83. [Medline].

  106. MacIsaac L, Grossman D, Balistreri E, Darney P. A randomized controlled trial of laminaria, oral misoprostol, and vaginal misoprostol before abortion. Obstet Gynecol. May 1999;93(5 Pt 1):766-70. [Medline].

  107. Major B, Gramzow RH. Abortion as stigma: cognitive and emotional implications of concealment. J Pers Soc Psychol. Oct 1999;77(4):735-45. [Medline].

  108. Mansfield C, Hopfer S, Marteau TM. Termination rates after prenatal diagnosis of Down syndrome, spina bifida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review. European Concerted Action: DADA (Decision-making After the Diagnosis of a fetal Abnormality). Prenat Diagn. Sep 1999;19(9):808-12. [Medline].

  109. Martin CW, Brown AH, Baird DT. A pilot study of the effect of methotrexate or combined oral contraceptive on bleeding patterns after induction of abortion with mifepristone and a prostaglandin pessary. Contraception. Aug 1998;58(2):99-103. [Medline].

  110. Mayr NA, Wen BC, Saw CB. Radiation therapy during pregnancy. Obstet Gynecol Clin North Am. Jun 1998;25(2):301-21. [Medline].

  111. Mcfarlane DR. Induced abortion: an historical overview. Am J Gynecol Health. May-Jun 1993;7(3):77-82. [Medline].

  112. Medich DS, Fazio VW. Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy. Surg Clin North Am. Feb 1995;75(1):77-88. [Medline].

  113. Miller VL, Ransom SB, Shalhoub A, Sokol RJ, Evans MI. Multifetal pregnancy reduction: perinatal and fiscal outcomes. Am J Obstet Gynecol. Jun 2000;182(6):1575-80. [Medline].

  114. Nielsen S, Hahlin M, Platz-Christensen J. Randomised trial comparing expectant with medical management for first trimester miscarriages. Br J Obstet Gynaecol. Aug 1999;106(8):804-7. [Medline].

  115. Oteri O, Hopkins R. Second trimester therapeutic abortion using mifepristone and oral misoprostol in a woman with two previous caesarean sections and a cone biopsy. J Matern Fetal Med. Nov-Dec 1999;8(6):300-1. [Medline].

  116. Owen J, Hauth JC. Vaginal misoprostol vs. concentrated oxytocin plus low-dose prostaglandin E2 for second trimester pregnancy termination. J Matern Fetal Med. Mar-Apr 1999;8(2):48-50. [Medline].

  117. Pakarinen P, Toivonen J, Luukkainen T. Randomized comparison of levonorgestrel- and copper-releasing intrauterine systems immediately after abortion, with 5 years' follow-up. Contraception. Jul 2003;68(1):31-4. [Medline].

  118. Papiernik E, Grange G, Zeitlin J. Should multifetal pregnancy reduction be used for prevention of preterm deliveries in triplet or higher order multiple pregnancies?. J Perinat Med. 1998;26(5):365-70. [Medline].

  119. Paul M. Office management of early induced abortion. Clin Obstet Gynecol. Jun 1999;42(2):290-305. [Medline].

  120. Paul M, Lichtenberg ES, Borgatta L. A Clinician's Guide to Medical and Surgical Abortion. New York, NY: Churchill Livingstone; 1999.

  121. Paul M, Schaff E, Nichols M. The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice. Am J Obstet Gynecol. Aug 2000;183(2 Suppl):S34-43. [Medline].

  122. Paul ME, Mitchell CM, Rogers AJ, Fox MC, Lackie EG. Early surgical abortion: efficacy and safety. Am J Obstet Gynecol. Aug 2002;187(2):407-11. [Medline].

  123. Penfield AJ. Gynecologic Surgery Under Local Anesthesia. Baltimore, Md: Urban & Schwarzenburg; 1986:65-94.

  124. Perry KG Jr, Rinehart BK, Terrone DA, Martin RW, May WL, Roberts WE. Second-trimester uterine evacuation: A comparison of intra-amniotic (15S)-15-methyl-prostaglandin F2alpha and intravaginal misoprostol. Am J Obstet Gynecol. Nov 1999;181(5 Pt 1):1057-61. [Medline].

  125. Pope LM, Adler NE, Tschann JM. Postabortion psychological adjustment: are minors at increased risk?. J Adolesc Health. Jul 2001;29(1):2-11. [Medline].

  126. Reeves MF, Lohr PA, Harwood BJ, Creinin MD. Ultrasonographic endometrial thickness after medical and surgical management of early pregnancy failure. Obstet Gynecol. Jan 2008;111(1):106-12. [Medline].

  127. Rosenblatt RA, Robinson KB, Larson EH, Dobie SA. Medical students' attitudes toward abortion and other reproductive health services. Fam Med. Mar 1999;31(3):195-9. [Medline].

  128. Sandstrom O, Brooks L, Schantz A, Grinsted J, Grinsted L, Jacobsen JD. Interruption of early pregnancy with mifepristone in combination with gemeprost. Acta Obstet Gynecol Scand. Oct 1999;78(9):806-9. [Medline].

  129. Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysis. Obstet Gynecol. May 1996;87(5 Pt 2):884-90. [Medline].

  130. Schaff EA, Fielding SL. A comparison of the Abortion Rights Mobilization and Population Council trials. J Am Med Womens Assoc. 2000;55(3 Suppl):137-40. [Medline].

  131. Schaff EA, Fielding SL, Eisinger SH, Stadalius LS, Fuller L. Low-dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception. Jan 2000;61(1):41-6. [Medline].

  132. Schaff EA, Fielding SL, Westhoff C, et al. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion: A randomized trial. JAMA. Oct 18 2000;284(15):1948-53. [Medline].

  133. Schüler L, Pastuszak A, Sanseverino TV, et al. Pregnancy outcome after exposure to misoprostol in Brazil: a prospective, controlled study. Reprod Toxicol. Mar-Apr 1999;13(2):147-51. [Medline].

  134. Selam B, Lembet A, Stone J, Lapinski R, Berkowitz RL. Pregnancy complications and neonatal outcomes in multifetal pregnancies reduced to twins compared with nonreduced twin pregnancies. Am J Perinatol. 1999;16(2):65-71. [Medline].

  135. Selam B, Torok O, Lembet A, Stone J, Lapinski R, Berkowitz RL. Genetic amniocentesis after multifetal pregnancy reduction. Am J Obstet Gynecol. Jan 1999;180(1 Pt 1):226-30. [Medline].

  136. Shanahan MA, Metheny WP, Star J, Peipert JF. Induced abortion. Physician training and practice patterns. J Reprod Med. May 1999;44(5):428-32. [Medline].

  137. Singh K, Ratnam SS. The influence of abortion legislation on maternal mortality. Int J Gynaecol Obstet. Dec 1998;63 Suppl 1:S123-9.

  138. Sorosky JI, Scott-Conner CE. Breast disease complicating pregnancy. Obstet Gynecol Clin North Am. Jun 1998;25(2):353-63. [Medline].

  139. Stephen JA, Timor-Tritsch IE, Lerner JP, Monteagudo A, Alonso CM. Amniocentesis after multifetal pregnancy reduction: is it safe?. Am J Obstet Gynecol. Apr 2000;182(4):962-5. [Medline].

  140. Stotland NL. The myth of the abortion trauma syndrome. JAMA. Oct 21 1992;268(15):2078-9. [Medline].

  141. Strauss LT, Herndon J, Chang J, Parker WY, Levy DA, Bowens SB. Abortion surveillance--United States, 2001. MMWR Surveill Summ. Nov 26 2004;53(9):1-32. [Medline].

  142. Trussell J, Ellertson C. Estimating the efficacy of medical abortion. Contraception. Sep 1999;60(3):119-35. [Medline].

  143. Ventura SJ, Mosher WD, Curtin SC, Abma JC, Henshaw S. Trends in pregnancies and pregnancy rates by outcome: estimates for the United States, 1976-96. Vital Health Stat 21. Jan 2000;(56):1-47. [Medline].

  144. Vintzileos AM, Ananth CV, Smulian JC, Beazoglou T, Knuppel RA. Routine second-trimester ultrasonography in the United States: a cost-benefit analysis. Am J Obstet Gynecol. Mar 2000;182(3):655-60. [Medline].

  145. Westfall JM, Sophocles A, Burggraf H, Ellis S. Manual vacuum aspiration for first-trimester abortion. Arch Fam Med. Nov-Dec 1998;7(6):559-62. [Medline].

  146. Wiebe E, Guilbert E, Jacot F, Shannon C, Winikoff B. A fatal case of Clostridium sordellii septic shock syndrome associated with medical abortion. Obstet Gynecol. Nov 2004;104(5 Pt 2):1142-4. [Medline].

  147. Wiebe ER. Comparing abortion induced with methotrexate and misoprostol to methotrexate alone. Contraception. Jan 1999;59(1):7-10. [Medline].

  148. Wiebe ER. Tamoxifen compared to methotrexate when used with misoprostol for abortion. Contraception. Apr 1999;59(4):265-70. [Medline].

  149. World Health Organization. Comparison of two doses of mifepristone in combination with misoprostol for early medical abortion: a randomised trial. World Health Organisation Task Force on Post-ovulatory Methods of Fertility Regulation. BJOG. Apr 2000;107(4):524-30. [Medline].

  150. Wu S. Medical abortion in China. J Am Med Womens Assoc. 2000;55(3 Suppl):197-9, 204. [Medline].

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Further Reading

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Keywords

abortion, surgical termination of pregnancy, elective termination of pregnancy, medical termination of pregnancy, voluntary abortion, therapeutic abortion, menstrual extraction, fetal reduction, pregnancy termination, partial birth abortion, Roe v Wade, intact dilatation and extraction, late-term abortion, elective induced abortion, surgical abortion, medical abortion, dilatation and suction curettage procedure, dilatation and evacuation procedure, labor induction, prostaglandin labor induction, saline infusion, hysterotomy, dilatation and extraction, medication-induced elective abortion, misoprostol, mifepristone, RU-486, incomplete abortion, complete abortion, therapeutic abortion, prostaglandin-induced second-trimester abortion, saline-induced abortion, dilatation and curettage

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Contributor Information and Disclosures

Author

Suzanne R Trupin, MD, Clinical Professor of Obstetrics and Gynecology, University of Illinois College of Medicine-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center
Suzanne R Trupin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society
Disclosure: Nothing to disclose.

Medical Editor

Steven David Spandorfer, MD, Assistant Professor, Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Medical College-Cornell University
Steven David Spandorfer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, and Endocrine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

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