Elective Abortion Treatment & Management

  • Author: Suzanne R Trupin, MD, FACOG; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Jan 31, 2012
 

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. Twin gestation is not considered a contraindication to medical abortion with mifepristone and misoprostol. Treatment results of medical abortion for twins were not significantly different than for singletons, although small differences cannot be excluded due to the limited number of twins.[9]

Abortion has been found to be significantly safer than carrying pregnancy to term. Terminating a pregnancy avoids the consequences of most cases of pregnancy-induced or associated hypertension and the major operative morbidity of cesarean delivery. Counseling regarding the risks and benefits has become a complex, controversial and, in some cases, outside the norm for medical procedures. The state of Texas currently requires the mandatory use of a pamphlet that must be presented to patients; the pamphlet specifically sites many more complications of surgical and medical abortion versus childbirth, in direct contrast to existing data.

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. In states that require parental notification or parental consent, local rules may also apply.

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 possible. The protocols may involve laminaria placed in one or more treatment settings, with or without additional misoprostol for ripening the cervix; however, 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.

For those receiving laminaria placement for a second trimester procedure, antibiotics beginning on the day of insertion is typical, with a regimen of doxycycline 100 mg twice daily or a single dose of 1 g of azithromycin.

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. In actual US Supreme Court reference materials there are statements that women may experience "regret...depression...loss of esteem"; however, most research fails to substantiate this, and, in fact, postabortion mental health benefits have been shown. Some studies show significant negative mental health effects of bearing an unwanted child, which others argue should be placed into the counseling context, although it seldom is. Most women experiencing depression postabortion experienced significant preabortion depression.[10]

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. The newest and what some consider the most intrusive law in one state involves mandatory visualization by a patient of the ultrasound, accompanied by an explanation of the findings of the procedure. 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.

In women with pregnancies at 14-21 weeks’ gestation, pretreatment with mifepristone doubled the chances of complete abortion in less than 15 hours and significantly reduced the induction-abortion interval without increased side-effects compared with misoprostol alone.[11]

A study by Grossman et al found that, in the United States, medical abortions prescribed through telemedicine were found to be as effective as a face-to-face meeting with a physician; acceptability was high among women who chose this method.[12]

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. But many of those reports actually involve hospitalized regimens. 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.
  • The package inserts for the medical regimen are critical to review with the patient and send home with her. They cover side effects, expected progress, and symptoms very completely.
  • On day 2 or day 3, the misoprostol (800 mcg vaginally or 400 mcg buccally or PO, but buccal administration preferred in some protocols) 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, without any bleeding yet, 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.
  • Fewer cases of serious infection have been reported from buccal and oral administration than after vaginal administration of the medication.
  • Tissue is not typically sent for confirmation.
  • After all routes of administration, sustained uterine contractions develop 1.5-2 hours after dosing. Few patients complete the process after the mifepristone alone; many complete within 4 hours of the misoprostol, but most complete within the first 48 hours after the misoprostol. The process is individual and the patient is counseled to expect this.
  • 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).[13]

A Cochrane review of the use of misoprostol and mifepristone as second trimester abortifacients reported the use of these drugs in Europe; however, they are not approved for this use in the United States.[14] The drugs are effective, but a high incidence of surgery for the removal of retained products and for bleeding was noted.

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.[15]

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. Laminaria do come in variable sizes, and the numbers used vary as to the length of gestation but may range from 1-2 at 14 weeks to 4-6 for the 24 week pregnancy.

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
Next

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. Surgical time out procedures and other standard operating room protocols are helpful.

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. In these cases, ultrasound dating of the pregnancy is important.

  • Obtaining ultrasonographic confirmation of gestational age prior to abortion is common practice.
  • A small, previously scarred, or stenotic cervical os may prevent adequate dilatation for a surgical abortion, but preoperative preparation with misoprostol can overcome the stenosis.
  • 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. Standard of care for second trimester procedures is to have ultrasound guidance.
  • 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.
  • The use of laminaria to facilitate cervical dilatation is recommended after 12 (to 14) weeks of gestation.
  • 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 by ultrasound 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, and documentation of findings, 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.
    • Few studies have looked at whether dilatation and evacuation is associated with less maternal morbidity and mortality than induction of labor.[16] A retrospective cohort study found that dilation and evacuation was more effective and safer than labor induction for second trimester abortion for fetal anomalies or fetal death.[17] The rate of maternal mortality for a woman with an intrauterine fetal demise has been reported to be slightly higher than the overall rate of maternal mortality.[18]
  • 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.
    • Intra-amniotic or intrafetal injection with digoxin to induce fetal death prevents the possibility of a live birth prior to the actual D&E procedure. Doses of digoxin used are typically 1-2 mg, although as low as 0.125 mg has been demonstrated to be effective. Studies show that this facilitates the procedure and no material side effects should be expected.
    • 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 or misoprostol regimens for labor induction, and these can be used in the second trimester of pregnancy. Larger doses of misoprostol (up to 200 mcg per dose) can safely be used in the second trimester than are used at term, although many still use in the range of 25-100 mcg per 4-hour dosing. The misoprostol can be given vaginally, orally, or in the buccal cavity.
    • 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.
  • Intrauterine device insertion
Previous
Next

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.
Previous
Next

Diet

Patients may eat a regular diet.

Previous
Next

Activity

  • Tampons, douching, and intercourse should be avoided for 1 week.
  • Heavy activity or lifting should be avoided for a few days.
Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Suzanne R Trupin, MD, FACOG  Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG 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.

Specialty Editor Board

Steven David Spandorfer, MD  Assistant Professor, Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Cornell Medical College

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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, 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.

References

  1. Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. Feb 2012;119(2 Pt 1):215-9. [Medline].

  2. Stulberg DB, Dude AM, Dahlquist I, Curlin FA. Abortion provision among practicing obstetrician-gynecologists. Obstet Gynecol. Sep 2011;118(3):609-14. [Medline].

  3. Kuppermann M, Nakagawa S, Cohen SR, et al. Attitudes toward prenatal testing and pregnancy termination among a diverse population of parents of children with intellectual disabilities. Prenat Diagn. Dec 2011;31(13):1251-8. [Medline].

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

  5. Borgatta L, Kapp N. Clinical guidelines. Labor induction abortion in the second trimester. Contraception. Jul 2011;84(1):4-18. [Medline].

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

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

  8. Clark W, Bracken H, Tanenhaus J, Schweikert S, Lichtenberg ES, Winikoff B. Alternatives to a routine follow-up visit for early medical abortion. Obstet Gynecol. Feb 2010;115(2 Pt 1):264-72. [Medline].

  9. Hayes JL, Achilles SL, Creinin MD, Reeves MF. Outcomes of medical abortion through 63 days in women with twin gestations. Contraception. Nov 2011;84(5):505-7. [Medline].

  10. Kornfield SL, Geller PA. Mental health outcomes of abortion and its alternatives: implications for future policy. Womens Health Issues. Mar-Apr 2010;20(2):92-5. [Medline].

  11. Ngoc NT, Shochet T, Raghavan S, et al. Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion: a randomized controlled trial. Obstet Gynecol. Sep 2011;118(3):601-8. [Medline].

  12. Grossman D, Grindlay K, Buchacker T, Lane K, Blanchard K. Effectiveness and acceptability of medical abortion provided through telemedicine. Obstet Gynecol. Aug 2011;118(2 Pt 1):296-303. [Medline].

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

  14. Wildschut H, Both MI, Medema S, Thomee E, Wildhagen MF, Kapp N. Medical methods for mid-trimester termination of pregnancy. Cochrane Database Syst Rev. Jan 19 2011;1:CD005216. [Medline].

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

  16. Edlow AG, Hou MY, Maurer R, Benson C, Delli-Bovi L, Goldberg AB. Uterine evacuation for second-trimester fetal death and maternal morbidity. Obstet Gynecol. Feb 2011;117(2 Pt 1):307-16. [Medline].

  17. Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol. Apr 2011;117(4):788-92. [Medline].

  18. Grimes DA. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol. Jan 2006;194(1):92-4. [Medline].

  19. Thompson KM, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception. Jan 2011;83(1):41-7. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  119. Lokeland M, Iversen OE, Dahle GS, Nappen MH, Ertzeid L, Bjorge L. Medical abortion at 63 to 90 days of gestation. Obstet Gynecol. May 2010;115(5):962-8. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  158. US Government Printing Office, Washington DC. Partial-Birth Abortion Ban Act of 2003.

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

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

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

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

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

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

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

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

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.