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. 
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 cites many more complications of surgical and medical abortion versus childbirth, in direct contrast to existing data.
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. 
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
Most first-trimester medical terminations are accomplished with the combination of mifepristone and misoprostol. Alternative regimens include methotrexate-misoprostol or misoprostol alone but these are less effective and cause additional side effects. 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. 
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. 
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. Ongoing pregnancy is rare, occurring in 0.1% of pregnancies to 49 days gestation and 0.5% between 50-77 days gestation. It is important to counsel women on the risk of limb defects and other congenital malformations possible after pregnancy exposure to misoprostol. Therefore, if a pregnancy continues, proceeding with surgery is recommended.
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 200 mg PO once as a single dose (FDA-approved regimen), is administered in the office. Misoprostol 800 mcg buccal administration is then administered at home 24-48 h after the mifepristone dose. Because most women will expel the pregnancy within 2-24 hr of taking misoprostol, discuss with the patient an appropriate location for her to be when she takes the misoprostol. 
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.
Other protocols recommend that on day 2 or day 3, the misoprostol (800 mcg vaginally or buccally, but buccal administration preferred in some protocols) is administered at home. 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 7-14 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). 
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.  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.
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.
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.
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.
Selective reduction includes the following:
Intracardiac injection (potassium chloride or digoxin)
Cord occlusion techniques, such as embolization with alcohol or enbucrilate gel; Nd:YAG laser photocoagulation; fetoscope cord ligation; bipolar cord coagulation; and monopolar cord coagulation
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.  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%).
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 typically begin on the day of insertion with a single dose of 200mg doxycycline or 500mg of azithromycin.
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.
Note the following:
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 curettes 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 previa, placenta accreta, and placenta percreta.It is important to document evaluation for placental location in women with a history of cesarean section and to obtain further evaluation and have adequate preparation in suspected cases of placenta accreta or percreta.
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 common functional cysts, no special treatment is usually necessary.
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 the sterile or "no-touch" technique should be used throughout the procedure. Laminaria insertion requires a single-toothed tenaculum to stabilize the cervix. A paracervical block with lidocaine can provide comfort. The cervix may require dilation with Pratt, Hegar or Denniston dilators if many laminaria must be placed. The patient must understand that laminaria insertion is the beginning of the abortion procedure. Patients should be counseled on the risk of chorioamnionitis, premature rupture of membranes and preterm birth should she choose not to proceed with the abortion following laminaria placement..
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. Dilating under ultrasound guidance is another option.
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. 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 have not shown large differences in efficacy.
Cannula size generally matches gestational age but is up to provider discretion. 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. Place the suction tip in the uterus, attach to the suction tubing and activate the suction.. Assess the position of the cannula in the uterus by gently touching the fundus and withdrawing 1-2cm prior to applying the suction. Gently rotate the suction tip while gradually withdrawing the syringe to the internal os (do not remove the suction tip beyond the cervix).
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.
Tissue inspection, and documentation of findings, for completeness is an essential part of the procedure.
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).
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 cervical dilation required depends on gestational age and is described above under Cervical dilation and preparation. 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 Sopher, Bierer, or ring forceps.. Uterotonics can help push the products of conception toward the internal os to facilitate the process.
Some providers rupture membranes and aspirate amniotic fluid with suction first. Other providers use forceps to remove fetal parts first and allow amniotic fluid to evacuate at the same time. Use forceps (Bierer or Sopher) to remove the fetus. Remove the placenta with forceps and/or suction. Some providers believe if the placenta is removed intact, sharp curettage is unnecessary. Other providers use minimal sharp curettage to confirm a gritty texture of the uterus and no retained placental fragments. 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.  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. 
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.
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 highest mortality rates for second-trimester abortions are associated with major surgical procedures (ie, hysterotomy, hysterectomy).
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. However, misoprostol may be used in these cases to contract the fetal parts into the lower uterine segment to permit an evacuation procedure.
The uterine segment is never developed well enough to place the incision there, so virtually all hysterotomies must be performed by classic uterine incisions.
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.
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.
Patients may eat a regular diet.
Intercourse should be avoided for 1 week.
There is no data to support an increased risk of infection with baths or tampon use.
Heavy activity or lifting should be avoided for a few days.
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