History
Women seeking terminations of pregnancy undergo a brief and targeted gynecologic and obstetric history. [17] Providers obtain information about any prior pregnancies and information regarding any treatment or care during the current pregnancy. The history taking should also focus on prior gynecologic disease, with particular attention to previous or current sexually transmitted infections (STIs). Medical history that might be important includes a history of diabetes, hypertension, heart disease, anemia, bleeding disorders, or gynecologic surgery. A history of active medical problems may indicate that the patient needs to be medically stabilized prior to the abortion or have the procedure performed in a facility that can handle special medical problems.
Maternal indications for abortion
With advances in perinatal care, few absolute medical contraindications exist for pregnancy. Perinatologists, obstetricians, and abortion counselors prefer to put the risks in the context of the statistical likelihood of complications, and then let the patient make her final decision. Nondirective counseling can help a woman select her choice.
Women take on less risk, regardless of health or gestational age, to terminate a pregnancy than to continue to term. These abortions have been termed therapeutic abortions.
Maternal medical conditions that carry significant risks in pregnancy include severe diabetes with retinopathy, cardiac or renal complications, advanced cardiac or respiratory disease, renal failure, sickle cell disease, autoimmune disease, and psychiatric disease.
Cardiac conditions that still carry maternal mortality rates of 5-15% include severe mitral stenosis, coarctation of the aorta, uncorrected tetralogy of Fallot, aortic stenosis, history of myocardial infarction, and the presence of artificial heart valves. Higher mortality rates have been reported in women with coarctation of the aorta with vascular involvement, pulmonary hypertension, Marfan syndrome with aortic involvement, and myocardial infarction in pregnancy.
Fetal indications for abortion
Fetal conditions that are incompatible with life include anencephaly, trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly, and some hydrocephalic cases.
Many hypoplastic cardiac conditions are also incompatible with life. With cardiac transplantation and extensive medical care, some infants can now survive with these defects.
The most common fetal anomalies encountered in abortion counseling include most fetal cardiac anomalies; trisomy 21; open and closed neural tube defects; limb, face, or cleft abnormalities; esophageal or duodenal atresia; chest and abdominal wall defects; cystic kidneys or hydronephrosis; intracranial calcifications suggestive of viral disease; or diaphragmatic defects.
Contraindications
Contraindications
Absolute contraindications are virtually unknown. If abortion presents a medical risk to the patient, then continuation of the pregnancy presents an even greater risk. The type and timing of an abortion procedure or method may be contraindicated based on the medical, surgical, or psychiatric condition of the patient, including the following:
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Medical abortion is contraindicated in patients with clotting disorders, severe liver disease, renal disease, cardiac disease, and chronic steroid use.
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Medical abortion is also contraindicated in women with no access to emergency services and no partners or family to be with the patient during the heaviest bleeding times.
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Surgical abortion is contraindicated in patients with hemodynamic instability, profound anemia, and/or profound thrombocytopenia. The conditions should be managed and the context of pregnancy continuation must be considered.
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The rare instance of placenta accreta and percreta in the second trimester may necessitate laparotomy with hysterotomy or hysterectomy.
Physical Examination
A brief physical examination is usually conducted prior to an abortion procedure. The focus is on dating the pregnancy, ensuring the absence of other gynecologic pathology (particularly STIs), and assessing the patient's suitability for an operative procedure under local sedation.
Note any vaginal or cervical discharge, the nature of the cervix, any lesions, and the position of the uterus. Document the presence or absence of any ovarian pathology.
If the patient is planned for general anesthesia, a typical screening preoperative physical examination can be performed.
