eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Elective Abortion

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

Updated: Nov 16, 2009

Introduction

Background

Elective termination of pregnancy remains common in the United States and worldwide. Accurate statistics have been kept since the enactment of the 1973 US Supreme Court decisions legalizing abortions.

• Since the 1973 decision, approximately 1.3-1.4 million abortions have been performed annually in the United States.
• Abortion is one of the most common medical procedures performed in the United States each year.
• Medical termination of pregnancy with mifepristone was approved in the United States in 2000 and is used in 31 countries worldwide. Approximately half of all abortions are performed with this method.
• More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives. Based on estimated lifetime risk, each American woman is expected to have 3.2 pregnancies, of which 2 will be a live birth, 0.7 will be an induced abortion, and 0.5 will be a miscarriage. Using 1996 data, this translates into 3.89 million live births, 1.37 million abortions, and 0.98 million miscarriages.
• Worldwide, some 20-30 million legal abortions are performed annually, with another 10-20 million abortions performed illegally (see The Alan Guttmacher Institute). Illegal abortions are unsafe and account for 13% of all maternal mortality and serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
• Statistic reporting in the United States is from the Centers for Disease Control (CDC, http://www.cdc.gov/reproductivehealth/Data_Stats/Abortion.htm). The Alan Guttmacher Institute (AGI) is a private organization that is not subject to the reporting limitations of state health departments. AGI contacts abortion providers directly and provides abortion data every 4-5 years. A previous report documented a discrepancy of approximately 12% between statistical figures presented by the CDC compared with those of AGI (the latter generally having higher estimates).
• In spite of the introduction of newer, more effective, and more widely available contraceptive methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these pregnancies, approximately half end in elective terminations.
• Each year in the United States, almost 3% of all reproductive-aged women terminate their pregnancies. While women of every social class seek terminations, the typical woman who terminates her pregnancy is young, white, unmarried, and poor.

Legalization of Abortion

Termination of pregnancy has been practiced since ancient times and by all cultures. The indications and social context for termination of pregnancy vary with culture and time.

The use of abortion to preserve the life of the mother has been widely accepted. Early Jewish scholars' interpretation of the Talmud required that the fetus be destroyed if it posed a threat to the mother during delivery. The ancient Greeks allowed abortion under certain circumstances. The ancient Romans did not consider a fetus a person until after birth, and abortion was practiced widely. Early Christians had varying practices regarding abortion. By 1869, the Catholic church declared abortion a sin punishable by excommunication.

Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of some medical personnel.

Since the landmark 1973 US Supreme Court decision legalizing abortion, hundreds of laws, federal and state, have been proposed or passed, making this the most actively litigated and highly publicized area in the field of medicine. Many of these laws are enjoined by court order and are thus not enforceable. They span a variety of controversial rulings, including provisions to establish viability before termination, parental or spousal notification, mandatory waiting periods, mandatory wording for counseling sessions, denial of public funding, denial of public funds for counseling (gag orders), targeted regulations specific to abortion providers, and provisions against specific abortion techniques.

Laws in several states mandate the examination of fetal tissue removed at the time of surgical abortion; how these laws will apply to medical abortions remains unclear. Because virtually all the laws regulating abortions were written before the legalization of medical abortions, some of these laws, such as the fetal tissue examination statutes, may be non sequiturs. Laws in some states criminalize these procedures, and performing a specific abortion constitutes a felony offense by the provider. Thirty-one states have forced parental consent or notification. Nine state courts block these laws. Thirty-one states ban abortion coverage for low-income women, and 19 states pay for abortion for low-income women.

Abortion politics even compromise access to emergency contraception thought to block implantation of a fertilized egg. Laws may be needed to protect victims of sexual assault. A pending bill in Maryland proposes that hospitals provide emergency contraception to all rape victims who seek treatment. However, the Maryland legislature adjourned in April of 2002 without passing this bill.

In the context of international laws, restrictive regulations and laws do more to increase the morbidity and mortality associated with abortions and do not present alternatives to obtaining abortions. In states where the laws are very restrictive, a trend exists toward delaying abortion procedures until later gestational ages, which makes access to care harder to achieve and actually increases medical risk unnecessarily.

Before Roe v Wade

Before the 19th century, most US states had no specific abortion laws. The provisions of British common law took precedence, and women had the right to terminate a pregnancy prior to viability. The first antiabortion legislation appeared in the 1820s; the preservation of pregnant women's health was the motivating force. Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion. During this time, the mortality rate from abortion was high, while the mortality rate from childbirth was less than 3%. By 1900, abortion in the United States at any time during pregnancy was a crime, with the exception of therapeutic abortion performed to save the mother's life.

The first US federal law on the subject was the notorious Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception to suppress the circulation of "obscene" materials. From 1900 until the 1960s, abortions were prohibited by law. However, the Kinsey report noted that premarital pregnancies were electively aborted, and public and clinician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.

During the 1950s, the practice of medicine came under increasing scrutiny, and guidelines were set to define the indications for therapeutic abortion. The guidelines allowed therapeutic abortion if (1) pregnancy would "gravely impair the physical and mental health of the mother," (2) the child born was likely to have "grave physical and mental defects," or (3) the pregnancy was the result of rape or incest.

In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and assured their right to autonomy in this process. No decision was more important than Griswold v Connecticut in 1965, which recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain contraceptives from their provider.

Roe v Wade

Roe v Wade was the culmination of the work of a wide consortium of individuals and groups who collectively crafted a strategy to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL). Lawyers were committed to expediting universal access to rights at a time when states were slowly liberalizing pertinent laws. Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.

In 1973, the Roe vs Wade law, in the opinion written by US Supreme Court judge Harry Blackmun (appointed by Richard Nixon), the court ruled that a woman had a right to induced abortion during the first 2 trimesters of pregnancy. He cited the safety of the procedures and the fundamental right of women to be free from the states' legislation concerning this inherently medical decision in the first trimester of pregnancy.

Blackmun sidestepped the question of viability of the pregnancy, specifically stating that scholars in many respected disciplines could not resolve this issue. Therefore, he felt that the court need not resolve this either. Since this ruling, the states have regained much control, and serious restrictions have been placed on abortion services. The Hyde amendment in 1976 prohibited the use of federal funds for abortions, except in the case of maternal life endangerment. Since then, an estimated one third of public funding recipients cannot obtain an abortion because of inability to pay for the service.

Viability determinations

Loosely defined, the term viability is the fetus' ability to survive extrauterine life with or without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation. However, there are no reliable or medically acceptable tests for this prior to 28 weeks' gestation.

The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (eg, anencephaly). In Colautti v Franklin, the court overturned a Pennsylvania law requiring physicians to follow specific directives in certain medical circumstances and recognized physician judgment as sacrosanct and important.

Parental consent

Parental consent is not required in the case of carrying a pregnancy to term, seeking contraception, or being treated for a variety of conditions, including sexually transmitted diseases. In 2 decisions handed down in 1991, Hodgson v Minnesota and Ohio v Akron Center for Reproductive Health, the US Supreme Court held that it is legal to have parental notification laws for abortions. These provisions often include waiting periods and fairly limited provisions for judicial bypass. On February 12, 2002, the West Virginia Senate Health and Human Resources Committee passed a bill requiring women seeking an abortion to give informed consent and wait for at least 24 hours before undergoing the abortion procedure. Specifically, the women must be furnished with written material, printed by the state, that would outline alternatives to abortion and the potential risks of the procedure.

On February 21, 2002, the Kentucky Senate passed 2 abortion-related bills. Kentucky SB 151 makes the existing consent laws more rigorous by requiring a woman to meet with a provider in person to receive preabortion counseling. Given that women must travel to access services, these laws quickly become restrictive for low-income care recipients.

Sociologic research shows that a good portion of minors (persons <18 y) do involve their parents in their decision to abort (45%). However, these laws have fostered a new ominous trend, ie, minors obtaining abortions significantly later in their pregnancies and often traveling great distances to states with no such law.

Intact dilation and extraction

The recently crafted political term "partial-birth abortion" loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This delineation is so overly broad that both legal and expert gynecologic testimony claim this definition encompasses virtually all methods of second-trimester abortion, including dilation and extraction and inductions.

In 19 US states, laws have banned these procedures; in only 8 US states are these laws enforced. In his first administration, US President Clinton vetoed 2 bills banning such abortions. The US Supreme Court ruled on June 28, 2000 that the Nebraska law and all other laws banning partial-birth abortion are unconstitutional. The reasons for the US Supreme Court's decision was that the Nebraska law did not contain an exception to protect the health of the mother, and the law was also thought to "unduly burden" a woman's choice to end her own pregnancy.

Recently, the US Department of Justice filed an amicus brief, on behalf of the Bush administration, asking the Sixth US Circuit Court of Appeals to reverse a decision by a lower court, which struck down the Ohio ban on late-term abortions. This ban was struck down by US District Court Judge Walter Rice because the legislation does not allow for the procedure when a woman's life is in danger.

Similarly, in Stenberg v Carhart, the US Supreme Court struck down Nebraska's ban on late-term abortions for the same reason, ie, because it may be necessary if a woman's life is in danger. However, the US Department of Justice states the Ohio ban is constitutional because it includes the provisions set up by the US Supreme Court in Stenberg v Carhart.

Providers

Providers of elective induced abortions are generally obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers—physicians, physician assistants, midwives, and nurse practitioners—to perform these procedures. Various factors over the years have influenced the number of providers.

Abortion is the only common surgical procedure that is elective in obstetric and gynecologic residencies. Thus, few board-certified gynecologists are actually qualified to perform the procedure. Increasing violence against providers and clinics has further decreased providers' willingness to provide abortion services. A "graying" has occurred in providers who continue to perform abortions. Most represent an older population of clinicians who became committed to providing access to safe, legal abortions after caring for young women who experienced morbidity or died from complications of an illegal abortion. For example, the number of abortion providers decreased by 14% from 1992-1996, suggesting a number of clinicians retired and new clinicians were not taking on the abortion services. The lack of abortion providers is underscored by the fact that 86% of counties in the United States have no abortion services.

Current New York City Mayor Michael Bloomberg, a Republican, proposed a policy that will include abortion training for medical residents in all 11 of the city's hospitals. Recently, the number of abortion providers in the United States has declined because of the aging population of providers and the lack of training during residency. Students, of course, are able to opt out of the training if they are morally opposed to abortion. In contrast, the Kentucky Senate also passed a bill that allows pharmacists who oppose abortion to opt out from dispensing medical abortion pills.

Medical abortion protocols have the potential to expand the number of available providers because arranging for backup with a provider who can perform a surgical abortion is necessary, while having a staff willing to assist at a surgical abortion is not necessary. The role of nurse practitioners, with valid prescription privileges, is unclear at the present time, but these providers may also aid in expanding abortion access.

The US Food and Drug Administration (FDA) has recently approved mifepristone (Mifeprex), also known as RU-486, for medical abortions. Multiple regimens for medical terminations using medications approved by the FDA for indications other than termination of pregnancy have come into use. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination. This may be difficult to track statistically but may actually lead to an increased number of abortions in the United States.

A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States. An understanding of the laws (enacted, enjoined, and pending) on local and federal levels is important to providers, and these legal ramifications are also reviewed in this article (see Medical/Legal Pitfalls).

Abortion postoperative care is often provided at sites where the abortion was not performed, and strategies for follow-up care for women whose pregnancies have been terminated are important for all providers of primary care for women.

Therapeutic Abortion

The ability to define therapeutic abortion performed for maternal indications is difficult because of the subjective nature of decisions made about potential morbidity and mortality in pregnant women. A variety of medical conditions in pregnant women have the potential to affect health and cause complications that may be life threatening.

Prenatal screening in the form of prenatal diagnostic testing continues to improve the antepartum diagnosis of fetal anomalies. The decision to continue or terminate a pregnancy complicated by fetal anomalies is a difficult decision. The most difficult decisions are associated with anomalies that are unpredictable or highly variable in their expression.

The increase in the use of assisted reproductive technologies has been associated with an enormous increase in multifetal pregnancies. Twins have increased in frequency from 1 set per 90 pregnancies to 1 set per 45 pregnancies. Higher-order multifetal pregnancies have quadrupled in the past 20 years. These pregnancies are complicated by increased fetal morbidity and mortality rates, which are largely caused by prematurity and growth retardation. Selective reduction has been introduced as a technology to improve perinatal outcomes in these pregnancies and has been successful in reducing preterm deliveries and associated perinatal morbidity and mortality.

Indications for pregnancy termination

Most providers consider all terminations to be elective, or a voluntary decision made by the patient herself. There are medical factors both maternal and fetal that contribute to the decision. These factors have been termed therapeutic abortion, defined as the termination of pregnancy for medical indications, including the following:

• Medical illness in the mother in which continuation of the pregnancy has the potential to threaten the life or health of the mother. Consider the present medical condition and a reasonable prediction of future circumstances, as well as the consequences of the pregnancy as it progresses.
• The total incidence of malignancy during pregnancy is estimated at 1 case per 1000 pregnancies. The most common cancers found in pregnant women mirror those found in their nonpregnant counterparts, to include the following:
  • Cervical cancer (1 case per 2200 pregnancies)
  • Breast cancer (1 case per 3000 pregnancies)
  • Melanoma (0.14-2.8 cases per 1000 pregnancies)
  • Ovarian cancer
  • Thyroid cancer
  • Leukemia (rare)
  • Lymphoma
  • Colorectal carcinoma (0.10-1.0 cases per 1000 pregnancies)
• Rape or incest
• Fetal anomalies when pregnancy outcome is likely to be birth of a child with significant mental or physical defects or high likelihood of intrauterine or neonatal death.
• Approximately 3-5% of all newborns have a recognizable birth defect. According to Cunningham and MacDonald¹⁰, the suggested causes of fetal anomalies are as follows:
  • Genetic (ie, chromosomal) (20-25%)
  • Fetal infections (3-5%)
  • Maternal disease (4%)
  • Drugs/medications (<1%)
  • Unknown (65-70%)
• Intrauterine fetal demise

Pathophysiology

Surgical termination

The development of accurate over-the-counter pregnancy tests allows for the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in this very early time frame have been termed menstrual extractions, a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed extremely early suction evacuations without histologic tissue confirmation, allowing for maximum confidentiality for both patient and provider.

Abortions performed prior to 9 weeks from the last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.

The following methods are available for surgical abortion:

• Manual vacuum aspiration (menstrual extraction) is used at 4-10 weeks' gestation and is 99.2% effective.
• Suction curettage is used at 6-14 weeks' gestation.
• Sharp curettage is used at 4-14 weeks' gestation but is not currently used because of increased blood loss and retained product of conception (POC) compared with suction.
• Dilation and extraction (D&E) is used at 14-24 weeks' gestation.
• Intact dilation and extraction (D&X) is used at more than 18 weeks' gestation, but is not performed in the US without prior feticide treatments due to current laws.
• Hysterotomy is used at 12-24 weeks of gestation and is reserved for the rare instances in which all other methods of abortion have failed or are contraindicated.
• Hysterectomy is reserved for rare instances in which other gynecological pathology dictates removal of the uterus.

Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 88% of abortions are performed at 13 weeks' gestation or less, 97% of abortions were performed using surgical methods in the early days of medical abortions, and now some centers are reporting more than 50% of first trimester procedures by medical abortion protocols.

In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. D&E is considered the safest form of abortion in the second trimester. In contrast, D&X is reputed to pose a greater health risk to the mother (increased risk of cervical incompetence, uterine rupture, abruption, amniotic fluid embolism, and uterine trauma) when compared with that of D&E. However, little published data exist regarding the frequency or complication rates for D&X since it has been a relatively ill-defined procedure until recently. A retrospective study has shown comparable complication rates and obstetric outcomes between these 2 procedures when performed by experienced physicians.

Labor induction methods have increasing morbidity/mortality as compared with that of D&E. Hysterectomy/hysterotomy procedures have the highest risk of complications but may still have a role in very rare clinical situations (eg, stenotic cervical os, placenta accreta, leiomyoma obstructing cervical os).

Women with a history of prior cesarean delivery are at particularly increased risk of morbidity/mortality when undergoing labor induction as a form of surgical abortion. Labor induction resulted in a 20-fold increased odds ratio of uterine rupture and 2-fold increased risk of blood transfusion in women with a history of prior cesarean delivery as compared with those without a uterine scar. Thus, women with a history of a prior cesarean delivery should undergo either D&E or D&X as the method of surgical abortion.

Medical termination

Medical abortion is a term applied to a medication-induced elective abortion. This can be accomplished with a variety of medications administered either singly or in succession. Medical abortion has a success rate that ranges from 75-95%, with approximately 2-4% of failed abortions requiring surgical abortion and approximately 5-10% of incomplete abortions, depending on the stage of gestation and the medical products used. For a review of multiple studies, see Kahn et al.¹ Patients who select a medical abortion express a slightly greater satisfaction with their route of abortion and, in most cases, express a wish to choose this method again should they have another abortion. Research needs to be performed to more clearly establish which protocol is best, which medications are preferable, and how successfully women and adolescents can diagnose a complete versus an incomplete abortion.

Although a critical shortage of providers exists who can provide surgical abortions, in a recent study by Koenig et al, providers who do not perform surgical abortions have indicated a willingness to provide medical abortions.²

Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Some patients require an emergency surgical abortion, and, for safety concerns, patients undergoing medical abortions need access to providers willing to perform an elective termination.

In September of 2000, the FDA approved mifepristone (RU-486) for use in a specific medical regimen that includes misoprostol administration for those who do not abort with mifepristone alone. Methotrexate and misoprostol are drugs approved for other indications that can also be used for medical termination of pregnancy. Additional research will determine exactly which regimen is ideal for medical abortions.

Medical abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed, the patient must be seen for evaluation of the completeness of the process.

The medical regimens initiate the process with progesterone receptor blockage by mifepristone without activating the receptor. This leads to a progesterone effect withdrawal from the decidua with ensuing necrosis and eventual detachment of the placenta at its implantation site. Following this with a prostaglandin, usually misoprostol, then leads to uterine activity and expulsion of the products of conception. It works best up to day 49 of pregnancy and regimens up to day 63 are effective as well.

A rare and serious infection of Clostridium sordellii is related to medical abortions. Four deaths associated with this infection have been reported since 2001. Fatal infections are rare, occurring in fewer than 1 in 100,000 uses of mifepristone medical abortions, which is far less fatal than penicillin-induced anaphylaxis (1 in 50,000 uses).

Frequency

United States

Abortion statistics are available from a variety of sources, including, the US Centers for Disease Control and Prevention, The Alan Guttmacher Institute, and the National Abortion Federation. Information and specific instructions regarding state requirements for abortion reporting are available from vital statistics offices in each state health department. Comprehensive statistical information is regarded as important in ensuring the utmost in patient safety.

In 1996, approximately 20 women for every 1000 women aged 15-44 years had an abortion, and for every 1000 live births, approximately 325 abortions were performed. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social milieu of abortion have led to more women seeking terminations later in pregnancy. In 2000, only 12.5% of abortions were performed in the second trimester of pregnancy (CDC), of which almost all between 13 and 20 weeks were surgical abortions, the others being performed by labor induction.

International

Globally, abortion mortality accounts for at least 13% of all maternal mortality. New estimates are that 50 million induced abortions are performed each year in developing countries, with approximately 20 million of these performed unsafely because of conditions or lack of provider training. Maternal mortality is 600,000 deaths per year due to pregnancy-related causes, and 99% of these deaths are in developing countries. While in the United States, only 1% of abortions are performed by induction, globally about 16% of all abortions, some as early as 12 weeks of gestation are performed by labor induction.

Mortality/Morbidity

The safety of abortion is well established, with infection rates less than 1%, and fewer than 1 in 100,000 mortalities occurs from first-trimester abortions. At every gestational age, elective abortion is safer for the mother than carrying a pregnancy to term. Medical abortions, or those performed primarily by medication prior to any surgical intervention, are even safer than surgical abortions at the same gestational age.

Mortality rates are highest with the most invasive procedures and with increasing gestational age, as follows: 0.4 of 100,000 cases at less than 8 weeks of gestation, 3 of 100,000 cases at 13-15 weeks of gestation, and 12 of 100,000 cases at more than 21 weeks of gestation. Causes of death include infection, hemorrhage, pulmonary embolism, anesthesia complications, and amniotic fluid embolism. Death rates with hysterotomy/hysterectomy are 64.9 of 100,000 cases at 13-15 weeks of gestation and 123 of 100,000 cases at more than 21 weeks of gestation.

Race

Unintended pregnancy rates are 40% among white women, 69% among black women, and 54% among Hispanic women. (Guttmacher Institute, July 2008)

Age

Abortion rates are highest among 20- to 24-year-old women; rates are lowest among women younger than 20 years and those older than 40 years. Although abortion rates are lower in the latter two groups, these women are far more likely to have a pregnancy termination if they become pregnant.

Clinical

History

Most terminations of pregnancy are performed after a brief and targeted gynecologic and obstetric history is obtained. Providers should obtain information about any prior pregnancies and information regarding any treatment or care during the current pregnancy. The history taking should also focus on prior gynecologic disease, with particular attention to previous or current sexually transmitted infections (STIs). Medical history that might be important includes a history of diabetes, hypertension, heart disease, anemia, bleeding disorders, or gynecologic surgery. A history of active medical problems may indicate that the patient needs to be medically stabilized prior to the abortion or have the procedure performed in a facility that can handle special medical problems.

• Maternal indications for abortion
  • With advances in perinatal care, few medical contraindications exist for pregnancy. Perinatologists, obstetricians, and abortion counselors prefer to put the risks in the context of the statistical likelihood of complications, and then let the patient make her final decision.
  • Women take on less risk, regardless of health or gestational age, to terminate a pregnancy than to continue to term. These abortions have been termed therapeutic abortions.
  • Maternal medical conditions that carry significant risks in pregnancy include severe diabetes with retinopathy, cardiac or renal complications, advanced cardiac disease, renal failure, sickle cell disease, autoimmune disease, and psychiatric disease.
  • Cardiac conditions that still carry maternal mortality rates of 5-15% include severe mitral stenosis, coarctation of the aorta, uncorrected tetralogy of Fallot, aortic stenosis, history of myocardial infarction, and the presence of artificial heart valves. Higher mortality rates have been reported in women with coarctation of the aorta with vascular involvement, pulmonary hypertension, Marfan syndrome with aortic involvement, and myocardial infarction in pregnancy.
  • Nondirective counseling can help a woman select her choice.
• Fetal indications for abortion
  • Fetal conditions that are incompatible with life include anencephaly, trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly, and some hydrocephalic cases.
  • Many hypoplastic cardiac conditions are also incompatible with life. However, with cardiac transplantation, some infants can now survive with these defects.
  • The most common fetal anomalies encountered in abortion counseling include most fetal cardiac anomalies; trisomy 21; open and closed neural tube defects; limb, face, or cleft abnormalities; esophageal or duodenal atresia; chest and abdominal wall defects; cystic kidneys or hydronephrosis; intracranial calcifications suggestive of viral disease; or diaphragmatic defects.

Physical

• A brief physical examination is usually conducted prior to an abortion procedure. The focus is on dating the pregnancy, ensuring the absence of other gynecologic pathology (particularly STIs), and assessing the patient's suitability for an operative procedure under local sedation.
• Note any vaginal or cervical discharge, the nature of the cervix, and any lesions. Document the presence or absence of any ovarian pathology.
• If the patient is planned for general anesthesia, a typical screening preoperative physical examination can be performed.

Causes

Contraindications

Absolute contraindications are virtually unknown. If abortion presents a medical risk to the patient, then continuation of the pregnancy presents an even greater risk. The type and timing of an abortion procedure or method may be contraindicated based on the medical, surgical, or psychiatric condition of the patient.

• Medical abortion is contraindicated in patients with clotting disorders, severe liver disease, renal disease, cardiac disease, and chronic steroid use.
• Medical abortion is also contraindicated in women with no access to emergency services and no partners or family to be with the patient during the heaviest bleeding times.
• Surgical abortion is contraindicated in patients with hemodynamic instability, profound anemia, and/or profound thrombocytopenia. The conditions should be managed and the context of pregnancy continuation must be considered.
• The rare instance of placenta accreta and percreta in the second trimester may necessitate laparotomy with hysterotomy or hysterectomy.
• Previous uterine incisions, including cesarean deliveries or multiple cesarean deliveries have been regarded as a contraindication to medical protocols, but some recent literature has suggested this may be safe.

Differential Diagnoses

Anemia
Cervicitis
Early Pregnancy Loss
Ectopic Pregnancy
Missed Abortion
Pelvic Inflammatory Disease

Other Problems to Be Considered

Bacterial vaginosis
Cervical dysplasia or neoplasia
Ovarian masses
Uterine fibroids
Uterine anomalies
Multifetal gestations
Fetal anomalies
Maternal illnesses
Maternal allergies
Bleeding or clotting disorders
Grand multiparity
Cervical incompetence
Sexual Assault
Psychological trauma
Bacterial endocarditis prophylaxis
Benign lesions of the uterine corpus
Gestational trophoblastic disease

Workup

Laboratory Studies

• Preabortion workup
  • Pregnancy tests are used to confirm the presence of a pregnancy, and home tests are reliable enough that their results can be accepted in some cases.
  • Hemoglobin (Hb) or hematocrit (Hct) levels are always assessed. A full CBC count is optional but may be indicated if abnormal findings are detected with the Hb or Hct test.
  • STI screening typically includes a gonorrheal culture (GC) or chlamydial test (CT), and targeting those aged 25 years and younger is considered appropriate. Screening for other STIs, such as syphilis or HIV disease, is usually prohibitively expensive; however, patients with positive results from the GC or CT should be offered these tests.
  • Rh typing is always performed. ABO typing is optional.
• Use of human chorionic gonadotropin titers
  • Human chorionic gonadotropin (hCG) titers are helpful in performing very early terminations, to establish the completeness of an abortion postoperatively in cases of persistent positive results from a urinary pregnancy test, or to establish the presence of an ectopic pregnancy. Prior to a medical abortion, ruling out ectopic pregnancy is mandatory. In medical abortion protocols, they can also be used to establish the arrest of viability of a pregnancy or to establish the completeness of a medical abortion.
  • Titer resolution is different between surgical and medical abortions. The titer should decrease to approximately 64% of its preabortion value within 24 hours of misoprostol being administered in medical abortion protocols. By 2 weeks, the titers should have dropped 99%.
  • If an abortion is being performed prior to 5 weeks from the LMP, obtaining titer values preoperatively can be very useful. Managing most abortion procedures without obtaining an hCG titer is within the standard of care.
• Wet preparations
  • Vaginal wet preparations, pH testing, and/or urine dipstick analysis are usually performed for standard indications.
  • If a woman is discovered to have a concomitant infection, it may require treatment before she has an abortion.
  • Screen for common sexually transmitted diseases (eg, chlamydia, gonorrhea, HIV, hepatitis B) in geographic areas with high prevalence (eg, urban, inner city) and in age groups commonly at risk (women <25 y).
• Additional testing is dictated by findings on history and physical examination.
  • Coagulation studies are indicated in patients with a history of bruising, abnormal bleeding, hemorrhage with previous surgical procedures, or petechiae on physical examination.
  • Liver function tests are indicated in patients with ethyl alcohol abuse, hepatitis, hepatomegaly, or jaundice.
  • Renal function tests are indicated in patients with a history of renal disease or dialysis.

Imaging Studies

Ultrasonography is invaluable but not always used in first-trimester terminations. The standard of care demands that second-trimester terminations be evaluated preoperatively with sonography. Documenting uterine abnormalities is important because failed terminations can occur in patients with double uterus or ectopic pregnancies.

• First-trimester sonography: The results of the examination are what is typically expected for a first-trimester screening examination. The focus is on fetal number, the size and nature of the gestational sac, the placental location, the uterus, and the ovaries. Document the presence and nature of a yolk sac.
• Second- and third-trimester sonography: For second- or third-trimester abortions, performing an ultrasound preoperatively is the standard of care. Conduct these examinations like other second-trimester screening examinations. If anomalies are detected, women should be offered a referral for targeted examinations that can delineate specific fetal disease conditions. Not unusually, women decline further investigation if their abortion decision does not hinge on the specific findings.

Other Tests

• Papanicolaou tests (Pap smears) are optional specifically prior to the procedure, but patients should be informed of their need for Pap smears as part of their postabortion contraceptive care.
• Genetic testing of an abnormal first-trimester pregnancy may be done either preoperatively or at the time of the abortion procedure. At the time of the procedure, either the fetus or the placenta may be tested, but these tests have to be prearranged and may be expensive.
• Autopsy should be considered for all second-trimester anomalies. The combination of genetic sampling (either by amniocentesis or cytogenetic specimen from the fetus and placenta) and autopsy should be offered to these patients to provide as much diagnostic information for the patient to facilitate counseling for future pregnancies.

Histologic Findings

Pathologic analysis of tissue is typically performed for documentation purposes, but visual inspection of the products of conception postprocedure is mandatory. Washing the blood clots off the tissue obtained prior to visual inspection is helpful, and the presence of villi can be detected more reliably after back-lighting the specimen. In cases in which very little tissue is obtained, the use of colposcopy may reveal villi. 

Placental analysis typically reveals products of conception consistent with gestational age. Preoperative ultrasound typically reveals placental abnormalities, such as a molar gestation or choriocarcinoma, when present. However, results from the histologic analysis that reveal the presence of a partial molar pregnancy or an incomplete molar pregnancy are not uncommon. See eMedicine article Hydatidiform Mole.

Requirements for pathological examination of products of conception (POC) after surgical abortion are also determined by state regulations. Many states require examination of fetal tissue after abortion. Request pathological examination of tissue in the following circumstances, even if no state requirement exists:

• Tissue obtained is less than expected based on gestational age.
• Scant tissue is obtained. Pathologic confirmation should be available within 24 hours if an ectopic pregnancy is suggested or within a week to 10 days if no pathology is suggested.
• Tissue is abnormal in appearance (eg, grapelike appearance consistent with molar pregnancy).
• Ectopic pregnancy is suspected.
• Sac, placental, or fetal tissue are not identifiable on gross examination in a first-trimester abortion.
• Placental and/or fetal tissue are not identifiable on gross examination in a second-trimester abortion.
• Many fetal anomalies can be detected upon anatomic inspection of the fetus, but only intact procedures or induction of labor reliably offer a fetal specimen that can be evaluated adequately.
• Tissue inconsistent with POC is identified in the specimen (eg, fat).

Treatment

Medical Care

Once the pregnancy has been confirmed, gestational age has been established, and the patient has decided to abort, the procedure offered typically reflects the patient's stage of gestation. Early abortions can be accomplished medically or surgically.

• Preoperative care of patients undergoing surgical abortion
  • Women often travel far for their abortion procedure and feel comfortable completing the preoperative preparation in a short office visit. In states where laws require waiting periods, this can be done in stages.
  • The assessment process involves only a targeted history, physical examination, laboratory work, and ultrasonographic evaluation (including dating of the pregnancy, if indicated) followed by a counseling session.
  • Assess the patient's need for pain relief and administer pain medication. (Ibuprofen 600-800 mg or equivalent medication is usually sufficient.) For suction curettage, administering 2.5-5 mg of diazepam to an unusually agitated patient on arrival is optional.
  • Second-trimester pregnancy preparation is more difficult. Preparing the cervix in less than 24 hours is almost impossible, but the basic assessment process is identical.
  • Ultrasonographic examinations should involve a more extensive examination, looking specifically for obvious fetal anomalies (see Imaging Studies).
  • Some centers also offer either intracardiac, intrathoracic, or an intra-amniotic injection of digoxin (1 mg), which ceases fetal cardiac activity and has very low transplacental medication leakage; therefore, it has been shown to be safe for the mother. Potassium chloride may be used as well, but complication rates have been higher. This ensures fetal death prior to fetal expulsion, regardless of the method of second-trimester abortion chosen.
• Abortion counseling
  • Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing to term, information and options for the technique of the abortion procedure, and, finally, information regarding a contraceptive decision. The risks and benefits of both medical and surgical abortions should be reviewed.
  • The counseling process is aimed primarily at the woman herself but may also include other persons she chooses to be involved. Studies indicate that males are involved in more than 40% of the decisions, but only scant research has been performed on male involvement in the process. Some women can reach a decision quickly; others take longer to decide. The counseling process should include referrals for those who need ongoing support.
  • Of utmost importance is to ensure that the patient has had enough time to consider her options and that she is not being coerced into her decision.
  • Many strategies can be used in the counseling session. Open-ended questions bring out issues that are pertinent to the woman and encourage meaningful exchange of dialogue. The patient's emotions should be validated, and the counselor should encourage the client to explore her feelings in more depth. Health care providers and counselors may not have the time or expertise to devote themselves to lengthy sessions, and not all women are able to complete the process in a day if these issues need to be explored before the abortion procedure.
  • Some state laws may apply to the counseling process. Some states have mandatory waiting times between the information session and the actual abortion, other states require family or parental notification, and some states mandate that certain subjects be covered. These laws are controversial because the validity of the materials may be outdated before the state has made any changes to the regulations. In some cases your local institution or funding agency may have rules regarding counseling. Usually, laws directed toward the providers also exist. Providers have an obligation to find out about their local laws and to comply with them.
• First- and second-trimester medical abortion
  • First-trimester terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or mifepristone with or without misoprostol. Other prostaglandins are used outside the United States. The simplest and most effective regimens are mifepristone and misoprostol together.
  • Medical abortions are indicated for women who consent to a medical abortion but are also willing to undergo a surgical abortion if the medical abortion fails. Gestational age for the FDA-approved protocol is 49 days, but many protocols, including up to 63 days from the LMP, are in the literature and in widespread clinical practice. Also, literature documenting the safety of medical abortion protocols at 11-13 weeks is accumulating. Only scant reports exist of continuing pregnancies after misoprostol, but the current data do not suggest a teratogenic action of misoprostol exposure during pregnancy.
  • Contraindications to medical abortion vary depending on the regimen selected. Contraindications to mifepristone include serious medical problems, such as cerebrovascular or cardiovascular disease, severe liver, kidney or pulmonary disease, preoperative anemia (<10 mg/dL), undiagnosed ectopic pregnancy, allergies, contraindications to prostaglandin use, active uterine bleeding, or large uterine leiomyomata.
  • The mifepristone/misoprostol appointment schedule is as follows:
    • On day 1, mifepristone, typically 200 mg (600 mg PO is FDA regimen), is administered in the office.
    • On day 2 or day 3, the misoprostol (800 mcg vaginally or 400 mcg PO) is administered at home. The FDA regimen is administering the medication on day 3 with a 4-hour observation period after insertion; however, if the patient is bleeding, the misoprostol may be used immediately, as soon as 8 hours after the mifepristone. Vaginal-moistened, rectal, sublingual, and buccal dosing are all possible. Protocols giving the medication 8 hours after mifepristone have been studied but are not as effective.
    • The patient returns to the office for a follow-up 7 days after the medical abortion to determine if the abortion has been completed. The amount of bleeding does not determine procedure completion.
    • Up to 43% of intersubject plasma concentration variability may occur with oral dosing and both food and antacids interfere with absorption and bioavailability.
    • Vaginal dosing reaches lower peak levels, but the levels are more sustained.
    • Tissue is not typically sent for confirmation.
    • After all routes of administration, sustained uterine contractions develop 1.5-2 hours after dosing
    • If the abortion is not complete, repeat misoprostol is administered or the patient may undergo a surgical abortion.
  • The methotrexate/misoprostol regimen is similar, as follows:
    • Methotrexate is injected on day 1.
    • On days 6-7, misoprostol is taken at home vaginally, and the patient returns to the office on day 8 to determine if the abortion has taken place. Misoprostol can be repeated and the patient monitored, or surgical abortion may be completed.
  • In a prospective trial, Dickinson and Doherty compared 3 regimens for third-stage management following intravaginal misoprostol pregnancy termination. One of the following 3 regimens was randomly used following fetal expulsion, and incidence of placental retention was observed: oxytocin (10 U IM), misoprostol (600 mcg PO), or no additional medication. The oxytocin group significantly increased placental expulsion rates compared with either misoprostol or no additional medicine (p=0.002). Blood loss was also significantly lower in the oxytocin group compared with the other 2 groups (p<0.001).³
• Prostaglandin-induced second-trimester abortion
  • Prostaglandin can be administered vaginally, orally, or via extraovular or intra-amniotic infusion. The intra-amniotic route was associated with greater rates of uterine rupture, although rarely, and has been abandoned largely in favor of the safety and technical ease of oral or vaginal administration.
  • Dosing regimens of 50-800 mcg have been studied with a wide range of induction schedules. About 98% of patients should deliver within 24 hours of doses 200-600 mcg and beginning and following doses are adequate.
  • In a comparison study by Perry of intra-amniotic 15-methyl-prostaglandin F2-alpha and intravaginal misoprostol, the mean evacuation time was slightly less in the intra-amniotic group and the rate of success by 24 hours was higher in the intra-amniotic group. The total complete abortion rate and incidence of severe effects were similar in both groups.⁴
  • After many regimens have been evaluated 400 mcg probably has greater success with tolerable side effects. Increasing dosing increases side effects without increasing efficacy. Most services use vaginal administration at 12-22 weeks' gestation. Every 3 hours has faster delivery times than every 6 hours, although every 6 hours is often used in the United States. Many protocols begin with 600 mcg first to enhance cervical ripening than decrease dose. Optional additional treatments included placental surgical removal and fetal extraction.
  • Rates of retained placenta vary from 10-60%. Patients with prior cesarean delivery have been treated safely but absolute risk of rupture is uncertain.
• Adjunctive methods of treatment
  • Feticide can be accomplished with intra-amniotic or intrafetal digitalis. This is easily performed and probably extremely safe for the mother. Psychological implications for the mother and provider are poorly understood. Time from intra-amniotic instillation to death of fetus is uncertain and care should still be taken to not violate partial-birth abortion laws if fetal extraction becomes necessary.
  • Laminaria: If laminaria have been used for cervical preparation, the time to delivery is typically hastened.
• Saline-induced abortion
  • Twenty years ago, saline-induced abortion was the only viable means of aborting a mid–second-trimester pregnancy, and most of the literature regarding this technique is from that era.
  • The process was long, laborious, had some potentially serious adverse effects, and has been abandoned for the greater maternal comfort offered by the dilatation and extraction procedures that subsequently have been developed. However, dilatation and extraction procedures are risky in the hands of inexperienced providers or providers who do not perform the procedures often enough to maintain competency.
  • In these circumstances, the saline-induced abortion can be safely used in the second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents.
    • Hypertonic saline, 20% sodium chloride injection (intra-amniotic injection 20%): In instillation techniques, the cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories).
      • Adult Dose - 40 g (200 mL) injection transabdominally into amniotic sac
      • Contraindications - Increased intra-amniotic pressure, blood disorders (ie, coagulation factor deficiencies, thrombocytopenia, fibrinolytic defects)
      • Interactions - Terbutaline may antagonize effect on uterine activity; indomethacin may increase time from induction to abortion
      • Pregnancy category C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
      • Precautions - Caution in patients with cardiac disease, hypertension, epilepsy, serious renal impairment, or pelvic adhesions
    • Hypertonic urea, urea 40-50% injection (Ureaphil): Used in the second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents. In instillation techniques, the cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories).
      • Adult Dose - Inject 80 g (40-50% solution in D5W) transabdominally into amniotic sac
      • Pediatric Dose - Not established
      • Contraindications - Documented hypersensitivity; severe renal impairment; frank liver disease; intracranial bleeding; sickle cell anemia
      • Interactions - Aspirin may increase time from induction to abortion
      • Pregnancy category C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
      • Precautions - Monitor for fluid and electrolyte imbalances
• Selective reduction
  • Intracardiac injection (potassium chloride or digoxin)
  • Cord occlusion techniques
    • Embolization with alcohol, enbucrilate gel
    • Nd:YAG laser photocoagulation
    • Fetoscope cord ligation
    • Bipolar cord coagulation
    • Monopolar cord coagulation

Surgical Care

Documentation is an important part of the surgical procedure. Preoperatively prepared standard operative reports are the standard of care and should include documentation of several important features, including the patient's anatomical assessment (including uterine size), the procedure and instruments used (including the size of the dilators and the cannula used), the amount of blood loss, and the amount of tissue obtained. Selection of the surgical abortion procedure primarily depends on the gestational age of the pregnancy, the comfort level of the patient, and provider preferences.

Adequate evaluation of uterine size is mandatory. Common causes of inadequate sizing by physical examination are obesity, uterine fibroids, patient apprehension with voluntary guarding, retroverted uterus, and firm abdominal musculature in young patients.

• Obtaining ultrasonographic confirmation of gestational age prior to abortion is common practice.
• A small or stenotic cervical os may prevent adequate dilatation for a surgical abortion.
• Uterine leiomyoma may make uterine sizing by physical examination erroneous, dilatation of the cervix difficult or impossible, and introduction of suction tips and curets into the uterine cavity difficult or impossible. Ultrasonographic guidance during the abortion procedure may be helpful.
• Previous uterine surgery may increase the risk of perforation during surgical abortion.
• Previous uterine surgery and high parity are associated with greater likelihood of placenta praevia, placenta accreta, and placenta percreta, yet transfusion need in these clinical settings is still remote and an emergency plan is all that is necessary.
• Scarring of the cervix caused by cone biopsy or delivery may increase the risk of cervical stenosis and damage to cervix at dilatation. Consider passive dilatation with osmotic dilators (eg, laminaria) or with the use of prostaglandins.
• Uterine anomalies (eg, uterine septum, double uterus) may make entry into and emptying of the uterus complicated. Ultrasonographic guidance during abortion for these procedures is recommended.
• Multiple gestations may make surgical abortion more technically challenging. Adequate cervical dilatation is recommended, and postevacuation assessment of an empty cavity is often helpful.
• For an adnexal mass, the physician must obtain an ultrasound to exclude ectopic pregnancy and to determine the nature of the mass. In the cases of the common functional cysts, no special treatment is usually necessary.

Selection of the surgical abortion procedure primarily depends on the gestational age of the pregnancy, the comfort level of the patient, and provider preferences.

Surgical procedures

• Cervical dilatation and preparation
  • Women having first-trimester terminations, particularly those at less than 10 weeks' gestation, rarely need preoperative cervical preparation. For those in the later part of the first trimester, preoperative dilatation with laminaria or medical treatment with prostaglandins is helpful and should be at the discretion of the provider performing the abortion. In the second trimester or beyond, the cervix needs preparation. Forceful cervical dilatation can lacerate the cervix, which can cause significant bleeding or, in rare cases, lead to cervical incompetence.
  • Laminaria japonicas are small sticks of presterilized seaweed that can be inserted preoperatively to dilate the cervix. They are generally thought to do this by absorbing water and swelling mechanically. Some believe that other hormonal mechanisms are triggered, allowing the cervix to dilate to larger than the physical size of the laminaria. Only one laminaria is required for dilating the cervix with a 10-week pregnancy. As the weeks and the amount of dilatation the pregnancy termination required progress, more laminaria are inserted and left for longer periods. Most laminaria need at least 4 hours to be useful, but overnight use is indicated in cases that are further along. Successive applications of increased numbers of laminaria can be used for more than 24 hours if the pregnancy is very advanced or if the cervix is unusually rigid.
  • Oral, buccal, or vaginally administered misoprostol in doses of 200-800 mcg can be helpful in cervical preparation.
  • Cases that might find cervical preparation helpful include uterine abnormalities and history of caesarian delivery.
  • Prior to insertion, the cervix is prepared with Betadine, but sterile technique has been shown to be as safe. Laminaria insertion is simple, often requiring a single-toothed tenaculum to stabilize the cervix and no anesthesia. For cases in which several laminaria must be inserted, 12 mL of lidocaine administered paracervically can provide comfort. The patient must understand that laminaria insertion is the beginning of the abortion procedure. Pregnancies have been safely carried to term after laminaria insertion and removal, but late-onset intrauterine infection or chorioamnionitis is a concern. Counseling is used to be sure the patient understands her risks once she starts the dilatation process.
  • Failure to dilate the cervix is not common, but if no dilators (the smallest is 3 mm) or laminaria can be admitted, this is the diagnosis. Rare cases exist in which the cervix is so scarred, mostly from previous pregnancies or deliveries, that the os cannot be viewed; the patient may be advised to have dilation with medical preparation such as vaginal misoprostol 200-800 mcg 2-6 hours preoperatively, but be aware that the patient may spontaneously go into labor or have a medical abortion. Waiting until the patient is further in pregnancy is an option, as is dilating while watching with sonographic control.
• Intraoperative care of patients undergoing surgical abortion
  • Most patients having an early termination of pregnancy can have their abortion performed under "vocal sedation" (ie, talking the patient through the procedure) and local sedation. Most patients do not require intravenous access for medication.
  • If heavy sedation is selected, then intravenous fluids with lactated Ringer solution or half isotonic sodium chloride solution is suitable, at rates appropriate for the patient's age and weight.
  • If a patient receives intraoperative sedation, appropriate monitoring includes vital sign assessment, assessment of the patient's degree of sedation and responses, and assessment of the patient's pulse oxygen level. Appropriately trained staff should be present as well.
• First-trimester surgical abortion
  • Early terminations are performed with little cervical dilatation and using a hand-held syringe or a small-bore cannula attached to a suction machine. Abortions performed with a syringe are referred to as manual aspirations. Some authors still call them menstrual extractions, from the days when abortion was more stigmatized and women did not want the procedure referred to as an abortion. Those performed with the suction generated by a vacuum aspirator are referred to as a vacuum aspiration. Both procedures take only a few minutes.
  • Single-toothed tenaculums are used to grasp the cervix after it has been prepared with Betadine. Local anesthetic is administered in a paracervical fashion. The agent used is usually 0.5-2% lidocaine or 1% Nesacaine. No epinephrine is necessary but epinephrine 1:200,000 may render the lidocaine more effective because it reduces absorption of lidocaine and decreases the risk of a vasovagal reaction. The maximum recommended dose of lidocaine is 4.5 mg/kg of body weight. In general, inject a maximum of 2 mL at the tenaculum site at 3, 5, 7, 9, and 12 o'clock; deeper blocks can be achieved with an additional maximum 2-mL injection at 2, 5, 7, and 10 o'clock. The local anesthetic takes effect rapidly, and studies of the exact route of administration (eg, several spots around the cervix or at the 3- and 9-o'clock positions) have not shown large differences in efficacy.
  • For gestations of 6 weeks or less, cannulas of 3-6 mm can be used. For gestations of 7-9 weeks, 5- to 9-mm cannulas are used. The suction cannulas can be soft or rigid or straight or bent, and experienced providers can use either type interchangeably. Both suction syringes and suction machines generate 60-70 mm Hg of pressure. Performing procedures at lower levels of suction prolongs the procedure and, therefore, increases bleeding and patient discomfort.
  • For suction curettage, placement of a paracervical block is common. After the suction tip is placed in the uterus (see above), attach it to the suction tubing and activate suction. The appropriately sized suction tip has to be selected and can be used to gently dilate the cervix with suction tips of increasing size or dilators of increasing size can be used before the actual surgical procedure.
    
    The procedure is complete when a gritty sensation is appreciated, when the uterine walls adhere to the suction tip (drag is felt), when foam appears in the tip/syringe, and when no more tissue is evacuated from the uterus. Examine POC. Gently rotate the suction tip from the fundus to the cervix until POC have been removed. Use of a metal curette after suction curettage is common but can increase bleeding. Soft suction tips are less likely to damage the uterus than rigid tips, but they have the disadvantage of a greater tendency to clog. Soft tips are less likely to permit entry into the uterus in the case of extreme flexion of the uterus or with the presence of myomas.
  • The amount of tissue obtained correlates with the stage of gestation and the fetal number. The amount of bleeding can be very slight, 5-25 mL for very early terminations, or as heavy as 100-250 mL. More than 200 mL of blood loss is usually indicative of uterine atony. Cervical lacerations increase the amount of blood lost.
  • Intravenous sedation with Versed (2.5-5 mg) can be performed, and rapidly acting narcotics can be added for pain relief. Others have had success with sublingual diazepam, and intramuscular Toradol (ketorolac tromethamine) can be used.
  • Abortions in the late period of the first trimester are performed with or without preoperative cervical dilatation with laminaria or misoprostol. If a woman is multiparous, no preoperative dilatation is usually necessary, although procedures under local anesthetic are more comfortable if the cervix has been prepared.
  • Sounding should be performed with the cannula to protect the uterus against perforation. The actual evacuation is performed by applying suction to the syringe or via the machine. The cervix is grasped with a single tooth tenaculum. After the suction tip is placed in the uterus, prepare the syringe by creating a vacuum and attach the tip to the syringe. Blood, POC, and bubbles will enter the syringe. Gently rotate the suction tip while gradually withdrawing the syringe to the internal os (do not remove the suction tip beyond the cervix).
  • The completeness of the procedure is ensured by the gritty feel of the uterus against the instrument, the sound of the uterine curettage, and the appearance of bubbles in the cannula. Sonographic confirmation of completeness is helpful in some cases. The procedure takes a few minutes to complete, and the estimated blood loss should be minimal (5- to 10-mL range for very early abortion and 50- to 100-mL range for later procedures).
  • Tissue inspection for completeness is an essential part of the procedure.
• Dilatation and curettage
  • This specifically is a term that is usually applied to a diagnostic gynecological procedure or the treatment of an incomplete abortion.
  • The procedure is usually accomplished with similar dilatation procedures, but uterine emptying is accomplished with a sharp metal curette. These curettes are more dangerous than the flexible or rigid plastic devices, which are used in the suction procedures, and are not recommended for abortion procedures. The use of intravenous oxytocin can also enhance contraction of the uterus at the end of the case. At the end of the procedure the uterus is decreased in size and an empty sac can be seen on ultrasound.
• Second-trimester dilatation and evacuation
  • Dilatation and evacuation is the safest and most common method of second-trimester termination for experienced providers. These procedures are accomplished with preoperative preparation similar to first-trimester preparation; however, the dilatation must be accomplished over hours and, in some cases, days. Dilatation and evacuation is not a risk factor for subsequent midtrimester pregnancy loss or spontaneous preterm birth. See Preoperative care of patients undergoing surgical abortion.
  • The procedure requires the cervix to be dilated to 2-3 cm, admitting at least a No. 16 Hegar dilator or a 53F dilator. The cervix is grasped with a single-toothed tenaculum after Betadine preparation. The procedure is accomplished using a combination of suction curettage and manual evacuation of the fetus and placenta. Ultrasonic guidance is valuable, and some providers use manual palpation of the fundus to guide the forceps used for evacuation. The forceps are used most carefully in the lower uterine segment. The types of forceps used are Soper, ring, or packing forceps, with Soper forceps being the most useful. Uterotonics can help push the products of conception toward the internal os to facilitate the process.
  • Rupture membranes and aspirate amniotic fluid with suction. This allows the uterus to contract, thereby closing the venous sinuses. This results in limitation of blood loss and reduction of the risk of an amniotic fluid embolism, one of the major causes of morbidity and mortality of late abortions. Further, evacuation of all the amniotic fluid allows for accurate measurement of blood loss. Use forceps (Bierer or Sopher) to remove the fetus. Remove the placenta with forceps and/or suction. Sharp curettage is performed with a curette. Use of intravenous oxytocin is standard practice. The procedure is completed when all of the fetus is identified on gross examination, the placenta is identified, the uterus decreases in size, vaginal bleeding is minimal, and no additional tissue is obtained on curettage.
  • The procedure is longer and more uncomfortable than a first-trimester procedure, but many patients can comfortably go through the procedure with local anesthesia. Blood loss for these procedures is 100-350 mL.
• Dilatation and extraction
  • This procedure is accomplished by cervical preparation similar to cases of dilatation and evacuation, but the fetus is removed in a mostly intact condition. The fetal head is made of cartilage and is able to be collapsed after the contents are evacuated so that it may pass through the cervix.
  • Current laws prohibit performing this technique on a live fetus and the definition of the law should be reviewed and it should be documented that this technique occurred.
  • Very few providers perform the procedure. It is usually reserved for cases of maternal medical complications or fetal abnormalities.
  • With an intact fetus, the family may hold their baby and have time to say good-bye as part of the grieving process. Reconstituting the fetal head with a jellied substance can restore fetal anatomy.
  • The procedure has also been referred to as intact dilatation and extraction and has been called partial-birth abortion by abortion opponents.
• Induction of labor
  • Most clinicians have experience with the standard Pitocin protocols for labor induction, and these can be used in the second trimester of pregnancy.
  • Premature rupture of membranes is one indication for this method.
  • Research generally indicates better success with prostaglandin methods, protocols using 200-600 mcg every 3 hours usually work the best. Special concerns are in cases of prior cesarean delivery.
• Hysterotomy
  • Hysterotomy is reserved for very few cases. The presence of large uterine leiomyomata has been an indication for hysterotomy in the performance of an abortion, and in the past, placental previa was another indication (recent reports have shown that a dilatation and evacuation procedure can be performed safely in some of these cases).
  • The uterine segment is never developed well enough to place the incision there, so virtually all hysterotomies must be performed by classic uterine incisions.
• Hysterectomy
  • Very few indications exist for the use of hysterectomies to terminate pregnancies.
  • The extrauterine vasculature that develops in pregnancy makes hysterectomy more dangerous, and the incidence of hemorrhage and complications rises.
  • For hysterectomy, the uterus can be removed by vaginal or abdominal approach, as dictated by the size of the uterus and the indication for the hysterectomy. POC are usually removed intact at the time of hysterectomy.
  • The patient is prepared and draped in the usual fashion for abdominal surgery. A skin incision is made, and the anterior abdominal wall is opened in the usual fashion. The uterus is identified, the uterine incision is made, and the uterine cavity is entered. The fetus is removed from the uterus in the sac, or the membranes are ruptured and the fetus is delivered. The placenta is then removed. Intravenous oxytocin is administered; intravenous antibiotics are optional. The uterine incision is closed, usually in 2 layers. After adequate hemostasis is obtained, the abdominal incision is closed in the usual fashion.
• Surgical sterilization
  • Bilateral tubal ligation via minilaparotomy, tubal fulguration, or tubal device occlusion is easily performed at the time of first- or second-trimester abortion of pregnancy.
  • Failure rates are high because of the enlarged tubal structure and lumen, but the magnitude of risk is not well established.

Consultations

• Consultation may be necessary for women with special situations; these may include one or more prior cesarean deliveries, placental implantation abnormalities, or maternal indications.
• The counseling process includes referrals for those who need ongoing support.

Diet

Patients may eat a regular diet.

Activity

• Tampons, douching, and intercourse should be avoided for 1 week.
• Heavy activity or lifting should be avoided for a few days.

Medication

A surgical abortion is usually performed under local anesthesia. For those modestly tolerant of pain, either intravenous sedation or a preoperative antianxiolytic agent can be administered. Nonsteroidal anti-inflammatory drugs (NSAIDs) have also been used for preoperative preparation. Narcotics can be used for pain control but are usually not necessary. A variety of agents may be useful for contracting the uterus postprocedure, although in a typical first-trimester procedure, these are not necessary. Agents useful to control bleeding include oxytocin, methylergonovine, or prostaglandins. Mechanical devices (typically intrauterine insertion of a Foley catheter) to control hemorrhage can also be useful. Now specific devices are available that allow for more fluid and coverage of larger uteri.

Postprocedure pain and cramping are effectively treated with a variety of analgesic agents (ie, NSAIDs, Tylenol, codeine, Vicodin).

Dinoprostone (Cervidil, Prepidil, Prostin E2) is a prostaglandin administered vaginally and is approved specifically for the use at term in labor for cervical preparation. It works almost as well as misoprostol, but it is very expensive and not used for abortions for this reason alone.

Prostaglandins

Abortifacient drugs of various types can be used for medical termination or treatment of ectopic pregnancy. Rarely, they are used to complete an incomplete surgical abortion. This class of drugs includes misoprostol, gemeprost, and PG05 (15MF2 alpha prostaglandin).

Misoprostol (Cytotec)

Not approved for use in pregnancy, yet is an invaluable medication widely used for cervical preparation for abortion, labor induction, and as a medical abortifacient. Provides safe, passive method of cervical dilatation and should be considered for preabortion ripening. In patients with a history of prior uterine or cervical surgery (ie, LEEP, cesarean delivery), prostaglandins are known risk factors for uterine perforation during surgical abortion. Can be administered PO or vaginally. Some studies show premoistened tabs placed vaginally helps absorption. Patients can be instructed in self-administration to help time the dose in synchrony with their abortion procedure.
In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the cervix of 8 mm or greater after 3 h of postintravaginal misoprostol at 400 mcg, whereas only 16.7% of women achieved this after 2 h at 600 mcg. The 600-mcg group had slightly greater adverse effects (eg, bleeding, abdominal pain, fever >38°C). Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of 100-400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical dilatation.

Dosing

Adult

Cervical ripening: 25-100 mcg (vaginally) for term pregnancies, lower doses may need to be repeated q4-6h; in conjunction with laminaria, doses of 200-400 mcg preabortion procedure may be helpful
Termination: 200-800 mcg; most patients do not need repeat dosing for 24 h

Pediatric

Not established

Interactions

Antacids containing magnesium may increase diarrhea

Contraindications

Documented hypersensitivity; pregnancy (if termination is not intended); glaucoma; sickle cell anemia; hypotension; mitral stenosis

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Inform patient of potential adverse effects (eg, GI distress, cramping, bleeding); GI distress slightly greater with PO administration.

Carboprost tromethamine (Hemabate)

Prostaglandin similar to F2-alpha (dinoprost) but has longer duration and produces myometrial contractions that induce hemostasis at placentation site, which reduces postpartum bleeding.

Dosing

Adult

250 mcg IM; repeat at 15- to 90-min intervals, not to exceed 2 mg

Pediatric

Not established

Interactions

Increases toxicity of oxytocic agents

Contraindications

Documented hypersensitivity; pelvic inflammatory disease

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in cardiovascular disease, asthma, hypotension or hypertension, adrenal disease, diabetes, renal or hepatic disease, a compromised uteri, or jaundice; do not inject IV (may induce hypertension and bronchospasm)

Local anesthetics

A few patients can tolerate cervical dilatation and suction curettage with no anesthesia and also through relaxation techniques. Paracervical blockade provides some additional cervical compliance in the dilatation phase and all the anesthetic necessary for early abortion procedures.

Lidocaine (Xylocaine)

Used for paracervical block to keep the patient comfortable during procedure. Local anesthetic blocks nerve impulses by decreasing sodium influx across neuronal cell membranes. Alternatively, chloroprocaine (Nesacaine) may be used.

Dosing

Adult

Popular mixtures used (12-20 mL in divided doses to be injected in each patient):
(1) 50 mL vial of 1% or 0.5% lidocaine and draw off 5 mL, (2) add 2-4 U (0.1 mL) of vasopressin, (3) add 5 mL of buffer (8.4% sodium bicarbonate)
If atropine is added, dose is 2 mg/50 mL
Deep injections are more efficacious than superficial; inject 10-15 mL halfway between the os and the periphery of the cervix at 4 sites (12-, 3-, 6-, and 9-o'clock positions) at a depth of three quarters to 1 inch

Pediatric

Not established

Interactions

Increased toxicity with cimetidine and beta-blockers; additive cardiodepressant action with procainamide and tocainide; increases effects of succinylcholine

Contraindications

Documented hypersensitivity; Adams-Stokes or Wolff-Parkinson-White syndrome; SA, AV, or intraventricular heart block if artificial pacemaker is not in place

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Associated with malignant hyperthermia; increased risk of adverse CNS and cardiac effects in elderly persons; seizures, heart block, and AV conduction abnormalities have occurred; caution with heart failure, hepatic disease, hypoxia, hypovolemia, shock, respiratory depression, and bradycardia

Antiprogesterones

Antiprogesterone class of drugs used for medical termination. Other potential uses include postcoital contraception, leiomyomatas, endometriosis, endometrial cancer, breast cancer, ovarian cancer, glaucoma, myomas, and Cushing syndrome. Antiprogesterones do not effectively treat ectopic pregnancy and should not be used for this indication.

Mifepristone (Mifeprex, RU-486)

Progesterone receptor antagonist that has 5-times greater affinity for the receptor than progesterone. By blocking progesterone, the hormone that maintains pregnancy, abortion can be completed. Cervix is softened and dilated; decidual necrosis and detachment of the pregnancy at the endometrium and uterine contractions ensue.

Dosing

Adult

600 mg PO on day 1 of medical abortion regimen; doses as low as 200 mg reported as efficacious

Pediatric

Not established

Interactions

Not studied yet; possibly ketoconazole, itraconazole, erythromycin, grapefruit juice; rifampin, dexamethasone, St John's Wort, some anticonvulsants

Contraindications

Documented hypersensitivity; confirmed/suspected ectopic pregnancy; undiagnosed adnexal mass; IUD in place; chronic adrenal failure; concurrent long-term corticosteroid therapy; hemorrhagic disorders; concurrent anticoagulation therapy; inherited porphyrias

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Abdominal pain, uterine cramping, nausea, vomiting, diarrhea

Antimetabolites

Methotrexate has been used for more than 15 years for the medical treatment of early, unruptured ectopic pregnancies. Success rate for this indication is greater than 90%. Adverse effects are minimal and regimens are cost effective. This offers effective destruction of rapidly dividing placental cells. Used for medical termination of pregnancy, although for complete expulsion, usually must be administered in conjunction with prostaglandin.

Methotrexate (Folex PFS, Rheumatrex)

Antimetabolite that works by blocking enzyme dihydrofolate reductase, thereby inhibiting folate production and, thus, DNA synthesis. Primarily affects rapidly dividing cells first, such as trophoblast cells.

Dosing

Adult

50 mg/m² IM; alternatively, 50 mg PO

Pediatric

Not established

Interactions

Oral aminoglycosides may decrease absorption and blood levels of concurrent PO MTX; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response; probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides (including TMP-SMZ) can increase plasma levels; may decrease phenytoin plasma levels; may increase plasma levels of thiopurines

Contraindications

Documented hypersensitivity; alcoholism; hepatic insufficiency; kidney disease; inflammatory bowel disease; clotting disorder; documented immunodeficiency syndromes; preexisting blood dyscrasias; bone marrow hypoplasia; leukopenia, thrombocytopenia; significant anemia (Hct <30%)

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Nausea, vomiting, diarrhea, hot flushes, headache, cramping, and dizziness; toxic adverse effects on hematologic, renal, GI, pulmonary, and neurological systems

Uterotonics

The rapid and complete emptying of the uterus usually provides a natural uterine contraction process that successfully halts postabortion blood loss and eventually leads to normal uterine blood loss and normal uterine involution back to the prepregnant state. The uterotonic medications are typically used to enhance this process or to halt immediate postabortion bleeding. In some cases, these drugs can be inducers of uterine activity that are potent enough to lead to abortion without other drugs or regimens.

Oxytocin (Pitocin)

Produces rhythmic uterine contractions and can stimulate the gravid uterus. Also has vasopressive and antidiuretic effects. Can also control postpartum bleeding or hemorrhage. When used as in labor protocols, can induce second-trimester abortion.

Dosing

Adult

10 U IM after delivery
Alternatively, 10-40 U IV in 1000 mL of IV fluid at rate high enough to control uterine atony

Pediatric

>12 years: Administer as in adults

Interactions

Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension

Contraindications

Documented hypersensitivity; cardiac arrhythmias with tachycardia

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Overstimulated uterus can be hazardous; hypertonic contractions can occur in a patient whose uterus is hypersensitive to oxytocin, regardless of whether it was administered appropriately; has intrinsic antidiuretic effect that, when administered by continuous infusion and patient is receiving fluids by mouth, can cause water intoxication

Ergot alkaloids

Also in the category of uterotonics and used almost exclusively for treatment of postabortal bleeding, atony, or hemorrhage.

Methylergonovine (Methergine)

Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens third stage of labor. Administer IM during puerperium, delivery of placenta, or after delivering anterior shoulder. Also may be administered IV, over no less than 60 s, but should not be administered routinely because it may provoke hypertension or a cerebrovascular accident. Monitor BP closely when administering IV.

Dosing

Adult

0.2 mg PO tid/qid for 2-7 d
Alternatively, 0.2 mg IV/IM repeated q2-4h prn

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Concurrent administration with vasoconstrictors or other ergot alkaloids may produce additive effect

Contraindications

Documented hypersensitivity; glaucoma; Tourette syndrome; anxiety; hypertension

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in sepsis, obliterative vascular disease, or hepatic or renal insufficiency

Sedatives

During surgical abortion, relaxation techniques and local anesthetic is typically all that is required for adequate pain relief. In some patients, the use of IV, PO, or SL sedatives can enhance this effect.

Midazolam (Versed)

Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Also useful for its amnestic effects.

Dosing

Adult

0.5-2 mg IV over 2 min; repeat q2-3min prn; total IV dose generally 2.5-5 mg

Pediatric

<12 years: Not established
>12 years: 0.5 mg IV over 2 min; repeat q3-4min prn

Interactions

Sedative effects may be antagonized by theophyllines; narcotics and erythromycin may accentuate sedative effects because of decreased clearance

Contraindications

Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma; sensitivity to propylene glycol (diluent)

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, pulmonary disease, renal impairment, and hepatic failure; Romazicon is a benzodiazepine antagonist used to reverse the effects of Versed (0.2-0.3 mg IV, may wear off faster than Versed)

Antiemetics

Antiemetics are not typically necessary unless patients have preexisting nausea and vomiting of pregnancy or have nausea and vomiting in reaction to general anesthesia.

Prochlorperazine (Compazine)

May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.

Dosing

Adult

5-10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid

Pediatric

2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d
IV dosing not recommended for children
0.1-0.15 mg/kg/dose IM and change to PO as soon as possible

Interactions

Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension

Contraindications

Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Drug-induced Parkinson syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most common extrapyramidal reaction in elderly persons; lowers seizure threshold, caution with history of seizures

Promethazine (Phenergan)

Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

Dosing

Adult

12.5-25 mg PO/IV/IM/PR q4h prn

Pediatric

Adolescents: Administer as in adults

Interactions

May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; children younger than 2 y (incidences of death due to respiratory depression)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; avoid accidental intra-arterial injections

Antibiotics

Most antibiotics are used prophylactically to prevent postoperative endometritis. Some institutions have used dosages that would cover chlamydia and gonorrhea because patients often cannot be contacted after an abortion.

Doxycycline (Vibramycin)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Prophylaxis of postabortion infections. If contraindicated, use erythromycin or ampicillin. Suspected cervicitis for chlamydia.

Dosing

Adult

New ACOG recommendations are 100 mg PO 1 h prior to abortion, then 200 mg PO postabortion; this regimen may produce nausea and vomiting
100 mg PO bid for 1-3 d postabortion

Pediatric

2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d, not generally applicable

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Erythromycin (E-Mycin, Ery-tab, Eryc, Erythrocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. Prophylaxis of postabortion infections. Use if doxycycline is contraindicated.

Dosing

Adult

333 mg PO tid for 3-7 d; alternatively 500 mg PO bid for 3-7 d

Pediatric

30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment; concomitant use of astemizole, cisapride, pimozide, or terfenadine

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; pseudomembranous colitis

Immune globulins

Pregnancies past 5 weeks of gestation may have an established fetal blood system, and Rh sensitization can occur without administration. Typically, no preadministration antibody screens are performed in this patient population.

Rh0(D) immune globulin (RhoGAM)

Given to Rh(-) mothers to avoid sensitization to Rh(+) fetal blood.

Dosing

Adult

<12 wk gestation: 50 mcg (minidose)
>12 wk gestation: 300 mcg
Administered up to 72 h postabortion

Pediatric

Adolescents: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; patients who have received Rh_o (D)-positive blood within the last 3 mo

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in thrombocytopenia, bleeding disorders, or IGA deficiency; anaphylactic shock or fever may occur; do not administer live virus vaccine within 3 mo

Metronidazole (Flagyl)

Recommended as an alternative for endometritis prophylaxis.

Dosing

Adult

500 mg PO tid for 7d postabortion when allergic to doxycycline; stat when treating suspected bacterial vaginosis prior to abortion

Pediatric

Not established

Interactions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

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.

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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

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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