Elective termination of pregnancy remains common in the United States and worldwide, and controversy and debate are ongoing.[1] Accurate statistics have been kept since the enactment of the 1973 US Supreme Court decisions legalizing abortions. Note the following:
Termination of pregnancy has been practiced since ancient times and by all cultures. The indications and social context for termination of pregnancy vary with culture and time.
The use of abortion to preserve the life of the mother has been widely accepted. Early Jewish scholars' interpretation of the Talmud required that the fetus be destroyed if it posed a threat to the mother during delivery. The ancient Greeks allowed abortion under certain circumstances. The ancient Romans did not consider a fetus a person until after birth, and abortion was practiced widely. Early Christians had varying practices regarding abortion. By 1869, the Catholic Church declared abortion a sin punishable by excommunication.
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of some medical personnel.
Since the landmark 1973 US Supreme Court decision legalizing abortion, hundreds of laws, federal and state, have been proposed or passed, making this the most actively litigated and highly publicized area in the field of medicine. Many of these laws are enjoined by court order and are thus not enforceable. They span a variety of controversial rulings, including provisions to establish viability before termination, parental or spousal notification, mandatory waiting periods, mandatory wording for counseling sessions, denial of public funding, denial of public funds for counseling (gag orders), targeted regulations specific to abortion providers, and provisions against specific abortion techniques.
Laws in several states mandate the examination of fetal tissue removed at the time of surgical abortion; how these laws will apply to medical abortions remains unclear. Because virtually all the laws regulating abortions were written before the legalization of medical abortions, some of these laws, such as the fetal tissue examination statutes, may be non sequiturs. Laws in some states criminalize these procedures, and performing a specific abortion constitutes a felony offense by the provider. Thirty-one states have forced parental consent or notification. Nine state courts block these laws. Thirty-one states ban abortion coverage for low-income women, and 19 states pay for abortion for low-income women.
In the context of international laws, restrictive regulations and laws do more to increase the morbidity and mortality associated with abortions and do not present alternatives to obtaining abortions. In states where the laws are very restrictive, a trend exists toward delaying abortion procedures until later gestational ages, which makes access to care harder to achieve and actually increases medical risk unnecessarily.
Advances in neonatal medicine leading to improved fetal survival very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on the beginning of life.[1]
Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments has kept the debate both vocal and contentious. These potential therapies may be indicated in the treatment of diabetes, Parkinson disease, kidney disease, and cartilage diseases, among others.
Current national regulations prohibit most fetal tissue research, but the National Institute of Health revealed late in the year 2000 that it would allow stem cell research. In June 2002, however, President Bush enacted a law restricting stem cell research to only preexisting cell lines and embryos "left over" from in vitro fertilization procedures.
Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface. The American Congress of Obstetrics and Gynecology specifically has a policy against the use of sex determination for the expressed purpose of selectively terminating female children.
Before Roe v Wade
Before the 19th century, most US states had no specific abortion laws. The provisions of British common law took precedence, and women had the right to terminate a pregnancy prior to viability. The first antiabortion legislation appeared in the 1820s; the preservation of pregnant women's health was the motivating force. Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion. During this time, the mortality rate from abortion was high, while the mortality rate from childbirth was less than 3%. By 1900, abortion in the United States at any time during pregnancy was a crime, with the exception of therapeutic abortion performed to save the mother's life.
The first US federal law on the subject was the notorious Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception to suppress the circulation of "obscene" materials. From 1900 until the 1960s, abortions were prohibited by law. During the 1950s, the practice of medicine came under increasing scrutiny, and guidelines were set to define the indications for therapeutic abortion. The guidelines allowed therapeutic abortion if (1) pregnancy would "gravely impair the physical and mental health of the mother," (2) the child born was likely to have "grave physical and mental defects," or (3) the pregnancy was the result of rape or incest.[4]
Prior to the 1960s, an estimated 9 of 10 out-of-wedlock pregnancies were electively aborted. These procedures were performed in a variety of medical and lay settings, and almost 20% of all pregnancy-related complications were due to illegal abortions (Kinsey). Public and clinician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and assured their right to autonomy in this process. No decision was more important than Griswold v Connecticut in 1965, which recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain contraceptives from their provider.
Roe v Wade
Roe v Wade was the culmination of the work of a wide consortium of individuals and groups who collectively crafted a strategy to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL). Lawyers were committed to expediting universal access to rights at a time when states were slowly liberalizing pertinent laws. Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
In 1973, the Roe vs Wade law, in the opinion written by US Supreme Court judge Harry Blackmun (appointed by Richard Nixon), the court ruled that a woman had a right to induced abortion during the first 2 trimesters of pregnancy. He cited the safety of the procedures and the fundamental right of women to be free from the states' legislation concerning this inherently medical decision in the first trimester of pregnancy.
Blackmun sidestepped the question of viability of the pregnancy, specifically stating that scholars in many respected disciplines could not resolve this issue. Therefore, he felt that the court need not resolve this either. Since this ruling, the states have regained much control, and serious restrictions have been placed on abortion services. The Hyde amendment in 1976 prohibited the use of federal funds for abortions, except in the case of maternal life endangerment. Since then, an estimated one third of public funding recipients cannot obtain an abortion because of inability to pay for the service.
Viability determinations
Loosely defined, the term viability is the fetus' ability to survive extrauterine life with or without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation. However, there are no reliable or medically acceptable tests for this prior to 28 weeks' gestation.
The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (eg, anencephaly). In Colautti v Franklin, the court overturned a Pennsylvania law requiring physicians to follow specific directives in certain medical circumstances and recognized physician judgment as sacrosanct and important.
Parental consent
Parental consent is not required in the case of carrying a pregnancy to term, seeking contraception, or being treated for a variety of conditions, including sexually transmitted diseases. In 2 decisions handed down in 1991, Hodgson v Minnesota and Ohio v Akron Center for Reproductive Health, the US Supreme Court held that it is legal to have parental notification laws for abortions. These provisions often include waiting periods and fairly limited provisions for judicial bypass. On February 12, 2002, the West Virginia Senate Health and Human Resources Committee passed a bill requiring women seeking an abortion to give informed consent and wait for at least 24 hours before undergoing the abortion procedure. Specifically, the women must be furnished with written material, printed by the state, that would outline alternatives to abortion and the potential risks of the procedure.
On February 21, 2002, the Kentucky Senate passed 2 abortion-related bills. Kentucky SB 151 makes the existing consent laws more rigorous by requiring a woman to meet with a provider in person to receive preabortion counseling. Given that women must travel to access services, these laws quickly become restrictive for low-income care recipients.
Sociologic research shows that a good portion of minors (persons < 18 y) do involve their parents in their decision to abort (45%). However, these laws have fostered a new ominous trend, ie, minors obtaining abortions significantly later in their pregnancies and often traveling great distances to states with no such law.
By 1999, 38 states had such laws, and 29 states enforce their laws. Currently, only Connecticut, Maine, and the District of Columbia have laws that affirm the rights of a minor to seek her own abortion. For a summary of laws, see Minors' Right to Consent to Health Care and to Make Other Important Decisions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents who may travel hundreds of miles to seek an abortion.
Parental consent is not required in the case of carrying a pregnancy to term, seeking contraception, or being treated for a variety of conditions, including sexually transmitted diseases. In 2 decisions handed down in 1991, Hodgson v Minnesota and Ohio v Akron Center for Reproductive Health, the US Supreme Court held that it is legal to have parental notification laws for abortions. These provisions often include waiting periods and fairly limited provisions for judicial bypass.
Mandatory waiting periods
Mandatory waiting periods mandate by law that the woman seeking to terminate a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives anywhere from 24 to 72 hours prior to her procedure.
These laws have the effect of increasing the percentage of second-trimester abortions in states with these laws. Given that women must travel long distances to access services, these laws quickly become restrictive for low-income care recipients.
State-developed counseling materials
A variety of state-developed counseling materials have come into use across the United States. These counseling materials may include falsified information such as suggesting an increased risk of breast cancer for women who have had an abortion, although a 2003 National Cancer Institute census report found no such link. Other states have developed unfounded and unreferenced materials on topics such as fetal pain, the psychological effects of abortion, and coercion.
Late-term abortions
Although only 2% of the population verbalizes opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.
By 1998, 28 states had passed bans on this procedure, referred to in the lay press as a partial-birth abortion, which is the medical procedure intact dilatation and extraction. The descriptive language in the US Criminal Code defines "partial-birth abortion" as "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This delineation is so overly broad that both legal and expert gynecologic testimony claim this definition encompasses virtually all methods of second-trimester abortion, including dilation and extraction and inductions.
In 19 US states, laws have banned these procedures; in only 8 US states are these laws enforced. In his first administration, US President Clinton vetoed 2 bills banning such abortions. The US Supreme Court ruled on June 28, 2000 that the Nebraska law and all other laws banning partial-birth abortion are unconstitutional. The reasons for the US Supreme Court's decision was that the Nebraska law did not contain an exception to protect the health of the mother, and the law was also thought to "unduly burden" a woman's choice to end her own pregnancy.
Similarly, in Stenberg v Carhart, the US Supreme Court struck down Nebraska's ban on late-term abortions for the same reason, ie, because it may be necessary if a woman's life is in danger. However, the US Department of Justice states the Ohio ban is constitutional because it includes the provisions set up by the US Supreme Court in Stenberg v Carhart.
Eroding abortion rights
Although the fundamental right to have an abortion has remained intact by basic statute, poor women have had their rights eroded by the Hyde amendment in 1976 that prohibited the use of federal funds for abortions except in the case of maternal life endangerment. This, in conjunction with a rise in the takeover of hospitals in some regions by religious organizations opposed to abortion and contraception, has restricted access to abortion. Almost one third of publicly funded recipients are prevented from having a termination by lack of access to care. Public controversy has raged on the specific question of whether individuals or institutions should be allowed to refuse medical care. Although 45 states have enacted laws allowing such refusal, only 5 have also enacted laws that require the provider to notify patients of their refusal. These provisions extend to contraceptive and sterilization services.
Providers
Providers of elective induced abortions are generally obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers—physicians, physician assistants, midwives, and nurse practitioners—to perform these procedures. Various factors over the years have influenced the number of providers.
Abortion is the only common surgical procedure that is elective in obstetric and gynecologic residencies. Thus, few board-certified gynecologists are actually qualified to perform the procedure. Increasing violence against providers and clinics has further decreased providers' willingness to provide abortion services. A "graying" has occurred in providers who continue to perform abortions. Most represent an older population of clinicians who became committed to providing access to safe, legal abortions after caring for young women who experienced morbidity or died from complications of an illegal abortion. The lack of abortion providers is underscored by the fact that 86% of counties in the United States have no abortion services.
New York City's former mayor, Michael Bloomberg, proposed a policy that would include abortion training for medical residents in all 11 of the city's hospitals. It has been shown that the availability and type of abortion training is independently associated with abortion procedural experience.[5] The number of abortion providers in the United States has declined because of the aging population of providers and the lack of training during residency.[5, 6] Students, of course, are able to opt out of the training if they are morally opposed to abortion.
Medical abortion protocols have the potential to expand the number of available providers because arranging for backup with a provider who can perform a surgical abortion is necessary, while having a staff willing to assist at a surgical abortion is not necessary. The role of nurse practitioners, with valid prescription privileges, is unclear at the present time, but these providers may also aid in expanding abortion access.
The US Food and Drug Administration (FDA) has recently approved mifepristone (Mifeprex), also known as RU-486, for medical abortions. Multiple regimens for medical terminations using medications approved by the FDA for indications other than termination of pregnancy have come into use. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination. This may be difficult to track statistically but may actually lead to an increased number of abortions in the United States.
Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (eg, family practitioners, nurses) can be taught to perform abortions safely. Physicians are generally receptive to the concept of legal abortions being available in the United States. Epidemiologic research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.
Keeping abortions safe, legal, and rare are the goals of abortion providers. For information from physicians regarding these goals, see Physicians for Reproductive Choice and Health.
As providers have decreased in number, women are traveling farther to obtain abortions, presenting later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.
Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.
A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.[7] An understanding of the laws (enacted, enjoined, and pending) on local and federal levels is important to providers, and these legal ramifications are also reviewed in this article.
Abortion postoperative care is often provided at sites where the abortion was not performed, and strategies for follow-up care for women whose pregnancies have been terminated are important for all providers of primary care for women.
The ability to define therapeutic abortion performed for maternal indications is difficult because of the subjective nature of decisions made about potential morbidity and mortality in pregnant women. A variety of medical conditions in pregnant women have the potential to affect health and cause complications that may be life threatening.
Prenatal screening in the form of prenatal diagnostic testing continues to improve the antepartum diagnosis of fetal anomalies. The decision to continue or terminate a pregnancy complicated by fetal anomalies is a difficult decision. The most difficult decisions are associated with anomalies that are unpredictable or highly variable in their expression.
The increase in the use of assisted reproductive technologies has been associated with an enormous increase in multifetal pregnancies. Twins have increased in frequency from 1 set per 90 pregnancies to 1 set per 45 pregnancies. Higher-order multifetal pregnancies have quadrupled in the past 20 years. These pregnancies are complicated by increased fetal morbidity and mortality rates, which are largely caused by prematurity and growth retardation. Selective reduction has been introduced as a technology to improve perinatal outcomes in these pregnancies and has been successful in reducing preterm deliveries and associated perinatal morbidity and mortality.
Indications for pregnancy termination
There are medical factors both maternal and fetal that contribute to the decision. These factors have been termed therapeutic abortion, defined as the termination of pregnancy for medical indications, including the following:
Medical illness in the mother in which continuation of the pregnancy has the potential to threaten the life or health of the mother is a factor. The maternal medical condition and a reasonable prediction of future circumstances as well as the consequences of the pregnancy as it progresses must be considered.
The total incidence of malignancy during pregnancy is estimated at 1 case per 1000 pregnancies. The most common cancers found in pregnant women mirror those found in their nonpregnant counterparts, to include the following:
Rape or incest and fetal anomalies when pregnancy outcome is likely to be birth of a child with significant mental or physical defects or high likelihood of intrauterine or neonatal death are also considered.
Approximately 3-5% of all newborns have a recognizable birth defect. According to Cunningham and MacDonald,[8] the suggested causes of fetal anomalies are as follows:
The data that indicate increased maternal risk from fetal demise primarily date from the preultrasonography era, when prolonged retained products of conception put the patient at risk of coagulopathies. Current management thus centers on prompt diagnosis and uterine evacuation, particularly in the second trimester.
The development of accurate over-the-counter pregnancy tests allows for the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in this very early time frame have been termed menstrual extractions, a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed extremely early suction evacuations without histologic tissue confirmation, allowing for maximum confidentiality for both patient and provider.
Abortions performed prior to 9 weeks from the last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.
The following methods are available for surgical abortion:
Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 89% occur in the first 12 weeks., As of 2011, medication abortion accounted for 23% of all abortions, an increase from 6% in 2001.[9]
In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. Hysterectomy/hysterotomy procedures have the highest risk of complications but may still have a role in very rare clinical situations (eg, stenotic cervical os, placenta accreta). D&E is considered the safest form of abortion in the second trimester. Little published data exist regarding the frequency or complication rates for D&X. A retrospective study has shown comparable complication rates and obstetric outcomes between these 2 procedures when performed by experienced physicians.[10]
Labor induction methods have an increased risk of complications such as retained placenta as compared with that of D&E.[11] The Society of Family Planning released second trimester induction guidelines in February of 2011.[12]
Women with a history of prior cesarean delivery are at increased risk of morbidity/mortality when undergoing labor induction as a form of surgical abortion. Labor induction has been associated with an increased odds ratio of uterine rupture and risk of blood transfusion in women with a history of prior cesarean delivery as compared with those without a uterine scar. Women with a history of a prior cesarean delivery may safely be offered D&E by a trained provider without increased risk.
Medical abortion is a term applied to a medication-induced elective abortion. This can be accomplished with a variety of medications administered either singly or in succession. Medical abortion with the combination of mifepristone and vaginal or buccal misoprostol has a success rate of 93-95% to 63 days gestation., Ongoing pregnancy is rare, occurring in <0.4%. It is more common, occurring in 3-5% of patients, to have retained products and these patients often require a suction procedure due to ongoing symptoms.[13] Research continues to be performed to more clearly establish which protocol is best, which medications are preferable, and best methods to diagnose a complete versus an incomplete abortion.
Although a critical shortage of providers exists who can provide surgical abortions, in a recent study by Koenig et al, providers who do not perform surgical abortions have indicated a willingness to provide medical abortions.[14]
Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Some patients require an emergency surgical abortion, and, for safety concerns, patients undergoing medical abortions need access to providers willing to perform an elective termination.
In September of 2000, the FDA approved mifepristone (RU-486) for use in a specific medical regimen that includes misoprostol administration for those who do not abort with mifepristone alone. Methotrexate and misoprostol are drugs approved for other indications that can also be used for medical termination of pregnancy.
Medical abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed, the standard has been that the patient must be seen for evaluation of the completeness of the process. Many providers have also routinely used ultrasonography to assess abortion outcome. However, a recent study showed that using a low-sensitivity pregnancy test and clinical examination is sufficient for completeness assessment.[15]
The medical regimens initiate the process with progesterone receptor blockage by mifepristone without activating the receptor. This leads to a progesterone effect withdrawal from the decidua with ensuing necrosis and eventual detachment of the placenta at its implantation site. Following this with a prostaglandin, usually misoprostol, then leads to uterine activity and expulsion of the products of conception. It works best up to day 49 of pregnancy and regimens up to day 63 are effective as well.
A rare and serious infection of Clostridium sordellii is related to medical abortions. Four deaths associated with this infection have been reported since 2001. Fatal infections are rare, occurring in fewer than 1 in 100,000 uses of mifepristone medical abortions, which is far less fatal than penicillin-induced anaphylaxis (1 in 50,000 uses). Few direct comparisons of surgical and medical abortions are available, but using the data from the distributor of the mifepristone, 11 pregnancy-related deaths occurred in 1.8 million medical terminations from approximately 2000-2011, with a mortality rate of 0.7/100,000, which is virtually identical to the rate of mortality from surgical abortions.
United States
Abortion statistics are available from a variety of sources, including, the US Centers for Disease Control and Prevention (CDC), The Alan Guttmacher Institute, and the National Abortion Federation. Information and specific instructions regarding state requirements for abortion reporting are available from vital statistics offices in each state health department. Comprehensive statistical information is regarded as important in ensuring the utmost in patient safety.
Each year, 1.7% of U.S. women aged 15-44 have an abortion. Half have had at least one prior abortion. 89% of abortions occur less than 12 weeks gestation.[9]
International
Globally, abortion mortality accounts for at least 13% of all maternal mortality. New estimates are that 50 million induced abortions are performed each year in developing countries, with approximately 20 million of these performed unsafely because of conditions or lack of provider training. Up to 44,000 abortion related deaths occurred in 2014. While in the United States, only 1% of abortions are performed by induction, globally about 16% of all abortions, some as early as 12 weeks of gestation are performed by labor induction.
The safety of abortion is well established, with infection rates less than 1%, and fewer than 1 in 100,000 mortalities occurs from first-trimester abortions. At every gestational age, elective abortion is safer for the mother than carrying a pregnancy to term. Medical abortions, or those performed primarily by medication prior to any surgical intervention, are even safer than surgical abortions at the same gestational age.
Mortality rates are highest with the most invasive procedures and with increasing gestational age, as follows: 0.4 of 100,000 cases at less than 8 weeks of gestation, 3 of 100,000 cases at 13-15 weeks of gestation, and 12 of 100,000 cases at more than 21 weeks of gestation. Causes of death include infection, hemorrhage, pulmonary embolism, anesthesia complications, and amniotic fluid embolism. Death rates with hysterotomy/hysterectomy are 64.9 of 100,000 cases at 13-15 weeks of gestation and 123 of 100,000 cases at more than 21 weeks of gestation.
Unintended pregnancy rates are 36% among non-Hispanic white women, 30% among non-Hispanic black women, and 25% among Hispanic women.[16]
Women in their 20s account for more than half of all abortions. Eighteen percent of U.S. Women obtaining abortion are teenagers. Although abortion rates are lower for women less than 20 and over 40, these women are far more likely to have a pregnancy termination if they become pregnant.[16]
Women seeking terminations of pregnancy undergo a brief and targeted gynecologic and obstetric history.[16] 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.
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 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.
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.
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:
Preabortion workup includes the following:
Additional testing is dictated by findings on history and physical examination, including the following:
Use of human chorionic gonadotropin titers include the following:
Ultrasonography is invaluable but not always used in first-trimester terminations. The standard of care demands that second-trimester terminations be evaluated preoperatively with sonography. Documenting uterine abnormalities is important because failed terminations can occur in patients with double uterus or ectopic pregnancies. It is also important to document any abnormal appearance such as suspected molar pregnancy. Pregnancies of unknown location must be followed to resolution.
The results of the examination are what is typically expected for a first-trimester screening examination. The focus is on fetal number, the size and nature of the gestational sac, the placental location, the uterus, and the ovaries. Document the presence and nature of a yolk sac.
For second- or third-trimester abortions, performing an ultrasound preoperatively is the standard of care. Conduct these examinations like other second-trimester screening examinations. It is important to document placental location, particularly in patients with prior cesarean sections, as the risk of a placenta accreta is increased. If an accreta is suspected on ultrasound or if the patient has a placenta previa and a prior uterine incision, further testing may be warranted prior to a procedure. If anomalies are detected, women should be offered a referral for targeted examinations that can delineate specific fetal disease conditions. Not unusually, women decline further investigation if their abortion decision does not hinge on the specific findings.
Papanicolaou tests (Pap smears) are optional specifically prior to the procedure, but patients should be informed of their need for Pap smears as part of their postabortion contraceptive care.
Genetic testing of an abnormal first-trimester pregnancy may be done either preoperatively or at the time of the abortion procedure. At the time of the procedure, either the fetus or the placenta may be tested, but these tests have to be prearranged and may be expensive.
Autopsy should be considered for all second-trimester anomalies. The combination of genetic sampling (either by amniocentesis or cytogenetic specimen from the fetus and placenta) and autopsy should be offered to these patients to provide as much diagnostic information for the patient to facilitate counseling for future pregnancies.
Pathologic analysis of tissue is typically performed for documentation purposes, but visual inspection of the products of conception postprocedure is mandatory. Washing the blood clots off the tissue obtained prior to visual inspection is helpful, and the presence of villi can be detected more reliably after back-lighting the specimen. In cases in which very little tissue is obtained, the use of colposcopy may reveal villi.
Placental analysis typically reveals products of conception consistent with gestational age. Preoperative ultrasound typically reveals placental abnormalities, such as a molar gestation or choriocarcinoma, when present. However, results from the histologic analysis that reveal the presence of a partial molar pregnancy or an incomplete molar pregnancy are not uncommon. See Medscape Drugs & Diseases article Hydatidiform Mole.
Requirements for pathological examination of products of conception (POC) after surgical abortion are also determined by state regulations. Many states require examination of fetal tissue after abortion. Request pathological examination of tissue in the following circumstances, even if no state requirement exists:
Many fetal anomalies can be detected upon anatomic inspection of the fetus.Well-trained pathologists can identify anomalies in both intact and D&E specimens.
Further workup with ultrasound or beta hcg levels is warranted in the following cases:
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.[17]
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.[18]
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.
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.[19]
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.[20]
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:
The methotrexate/misoprostol regimen is similar, as follows:
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).[22]
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.[23] The drugs are effective, but a high incidence of surgery for the removal of retained products and for bleeding was noted.
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.
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:
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:
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.[25] 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.[11]
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.
Hysterotomy
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.
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.
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.
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.
A surgical abortion is usually performed under local anesthesia. For those modestly tolerant of pain, either intravenous sedation or a preoperative antianxiolytic agent can be administered. Nonsteroidal anti-inflammatory drugs (NSAIDs) have also been used for preoperative preparation. Narcotics can be used for pain control but are usually not necessary. A variety of agents may be useful for contracting the uterus postprocedure, although in a typical first-trimester procedure, these are not necessary. Agents useful to control bleeding include oxytocin, methylergonovine, or prostaglandins. Mechanical devices (typically intrauterine insertion of a Foley catheter) to control hemorrhage can also be useful. Now specific devices are available that allow for more fluid and coverage of larger uteri.
Postprocedure pain and cramping are effectively treated with a variety of analgesic agents (ie, NSAIDs, Tylenol, codeine, Vicodin).
Dinoprostone (Cervidil, Prepidil, Prostin E2) is a prostaglandin administered vaginally and is approved specifically for the use at term in labor for cervical preparation. It works almost as well as misoprostol, but it is very expensive and not used for abortions for this reason alone.
Clinical Context: Progesterone receptor antagonist that has 5-times greater affinity for the receptor than progesterone. By blocking progesterone, the hormone that maintains pregnancy, abortion can be completed. Cervix is softened and dilated; decidual necrosis and detachment of the pregnancy at the endometrium and uterine contractions ensue. The FDA-approved dosage regimen consists of a single PO dose of mifepristone on Day 1, followed 24-48 h later by a single buccal dose of mifepristone.
Antiprogesterone class of drugs used for medical termination. Other potential uses include postcoital contraception, leiomyomatas, endometriosis, endometrial cancer, breast cancer, ovarian cancer, glaucoma, myomas, and Cushing syndrome. Antiprogesterones do not effectively treat ectopic pregnancy and should not be used for this indication.
Clinical Context: Not approved for use in pregnancy, yet is an invaluable medication widely used for medical abortion, cervical preparation for abortion, and labor induction. Provides safe, passive method of cervical dilatation and should be considered for preabortion ripening in later first trimester cases or in cases of cervical stenosis. There is some association with uterine rupture when using misoprostol for labor induction in patients with prior cesarean section so it should be used with caution.
The FDA-approved dosage regimen consists of a single PO dose of mifepristone on Day 1, followed 24-48 h later by a single buccal dose of mifepristone. 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.
In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the cervix of 8 mm or greater after 3 h of postintravaginal misoprostol at 400 mcg, whereas only 16.7% of women achieved this after 2 h at 600 mcg. The 600-mcg group had slightly greater adverse effects (eg, bleeding, abdominal pain, fever >38°C). Dosage intended for cervical ripening can induce abortion in some patients.
Clinical Context: Prostaglandin similar to F2-alpha (dinoprost) but has longer duration and produces myometrial contractions that induce hemostasis at placentation site, which reduces postpartum bleeding.
Some agents in this category can stimulate uterine contractility and result in expulsion of the fetus. They can be used to induce abortion between 13-20 weeks of pregnancy.
Clinical Context: Antimetabolite that works by blocking enzyme dihydrofolate reductase, thereby inhibiting folate production and, thus, DNA synthesis. Primarily affects rapidly dividing cells first, such as trophoblast cells.
Methotrexate has been used for more than 15 years for the medical treatment of early, unruptured ectopic pregnancies. Success rate for this indication is greater than 90%. Adverse effects are minimal and regimens are cost effective. This offers effective destruction of rapidly dividing placental cells. Used for medical termination of pregnancy, although for complete expulsion, usually must be administered in conjunction with prostaglandin.
Clinical Context: Used for paracervical block to keep the patient comfortable during procedure. Local anesthetic blocks nerve impulses by decreasing sodium influx across neuronal cell membranes. Alternatively, chloroprocaine (Nesacaine) may be used.
A few patients can tolerate cervical dilatation and suction curettage with no anesthesia and also through relaxation techniques. Paracervical blockade provides some additional cervical compliance in the dilatation phase and all the anesthetic necessary for early abortion procedures.
Clinical Context: Produces rhythmic uterine contractions and can stimulate the gravid uterus. Also has vasopressive and antidiuretic effects. Can also control postpartum bleeding or hemorrhage. As the majority of oxytocin receptors develop in the late second to early third trimester, oxytocin is less effective than misoprostol for labor induction in the second trimester. However, high dose oxytocin protocols may be used where prostaglandins are not available. (Labor induction abortion in the second trimester, Society of Family Planning Clinical Guidelines, Contraception 2011.)
The rapid and complete emptying of the uterus usually provides a natural uterine contraction process that successfully halts postabortion blood loss and eventually leads to normal uterine blood loss and normal uterine involution back to the prepregnant state. The uterotonic medications are typically used to enhance this process or to halt immediate postabortion bleeding. In some cases, these drugs can be inducers of uterine activity that are potent enough to lead to abortion without other drugs or regimens.
Clinical Context: Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding. Administer IM during puerperium, delivery of placenta, or after delivering anterior shoulder. Also may be administered IV, over no less than 60 s, but should not be administered routinely because it may provoke hypertension or a cerebrovascular accident. Monitor BP closely when administering IV.
Also in the category of uterotonics and used almost exclusively for treatment of postabortal bleeding, atony, or hemorrhage.
Clinical Context: Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Also useful for its amnestic effects.
During surgical abortion, relaxation techniques and local anesthetic is typically all that is required for adequate pain relief. In some patients, the use of IV, PO, or SL sedatives can enhance this effect.
Clinical Context: May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.
Clinical Context: Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.
Antiemetics are not typically necessary unless patients have preexisting nausea and vomiting of pregnancy or have nausea and vomiting in reaction to general anesthesia.
Clinical Context: Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Prophylaxis of postabortion infections. If contraindicated, use erythromycin or ampicillin. Suspected cervicitis for chlamydia.
Clinical Context: Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. Prophylaxis of postabortion infections. Use if doxycycline is contraindicated.
Clinical Context: Recommended as an alternative for endometritis prophylaxis.
Most antibiotics are used prophylactically to prevent postoperative endometritis. Some institutions have used dosages that would cover chlamydia and gonorrhea because patients often cannot be contacted after an abortion.
Clinical Context: Given to Rh(-) mothers to avoid sensitization to Rh(+) fetal blood.
Pregnancies past 5 weeks of gestation may have an established fetal blood system, and Rh sensitization can occur without administration. Typically, no preadministration antibody screens are performed in this patient population.
Clinical Context: Naproxen is available in both prescription and nonprescription doses. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. The daily cost is approximately $3.00, compared with $0.14 for generic ibuprofen.
Clinical Context: Ibuprofen is available in both prescription and nonprescription doses. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. If not contraindicated, it is the drug of choice for treatment of mild to moderate pain.
Clinical Context: Diclofenac is one of a series of phenylacetic acids that have demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis.
Because diclofenac can cause hepatotoxicity, liver enzymes should be monitored in the first 8 weeks of treatment. Diclofenac is rapidly absorbed; metabolism occurs in the liver via demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium. Diclofenac carries a relatively low risk of bleeding gastrointestinal (GI) ulcers.
Clinical Context: Ketoprofen inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Smaller initial dosages are particularly indicated in the elderly and in those with renal or liver dysfunction. Doses higher than 75 mg do not improve therapeutic response and may be associated with a higher incidence of adverse effects.
Clinical Context: Meclofenamate inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Compared with other NSAIDs, it is associated with a higher incidence of diarrhea.
Clinical Context: Mefenamic acid inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Compared with other NSAIDs, it is associated with a higher incidence of diarrhea.
Clinical Context: This is the drug of choice (DOC) for treating pain in patients with documented hypersensitivity to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), who are diagnosed with upper gastrointestinal disease, or who take oral anticoagulants.
Clinical Context: Acetaminophen and codeine combination is used for the treatment of mild to moderate pain.
Clinical Context: This combination is used for the relief of moderate to severe pain.
Clinical Context: The combination of oxycodone and acetaminophen is used for the relief of moderate to severe pain. It is the DOC for aspirin-hypersensitive patients.
NSAIDs are readily available, relatively inexpensive, and have a low side effect profile when used cautiously and in those who have no contraindications. Diclofenac, ibuprofen, ketoprofen, meclofenamate, mefenamic acid, and naproxen are some of the NSAIDs approved by the US Food and Drug Administration (FDA) to treat pain. A variety of opioids can also be used to treat cramping.
Postoperative care of a patient after surgical abortion includes the following:
Regarding uterine perforation, if the patient had a fundal perforation with no suction applied, then observation for a few hours and evaluation of Hb levels is the standard of care.
When evaluating for acute abdominal pain postabortion, consider acute hematometra, retained products of conception, pelvic infection, or perforation with or without bowel involvement. In patients with prior cesarean deliveries, consider abnormal placentation.
Postoperative bleeding after a surgical abortion is different in timing, amount, and sequence to the bleeding post medical abortion. The amount and duration depends upon the gestational age of the pregnancy terminated.
Note the following:
The following are medications used to manage patients undergoing an elective abortion:
Effective contraception is the only reasonable strategy for abortion prevention.
Studies show that providing long-acting reversible contraceptives (LARC)—which would include the copper T intrauterine device (IUD), the levonorgestrel-releasing IUD (LNG-IUD), and the single-rod subdermal implant—provide the best statistical prevention of repeat abortion as well as being a possible contraceptive alternative for the largest number of patients and being cost effective in the long term.[26]
Complications of surgical abortion vary with the technique used, training of the provider, and the gestational age of the pregnancy. In general, the more advanced the gestational age at abortion, the higher the complication rate, and the more invasive the operative procedure, the higher the complication rate.
Complication rates are low: 0.071% for hospitalization and 0.846% for minor complications. Abortion complications requiring hospitalization include incomplete abortion (0.028%), sepsis (0.021%), uterine perforation (0.009%), vaginal bleeding (0.007%), inability to abort (0.003%), and combined pregnancy (0.002%). Minor abortion complications include infection (0.46%), repeat suction (0.18%), cervical stenosis (0.016%), cervical tear (0.01%), seizure (0.004%), and underestimate of dates (0.006%).
Manual vacuum aspiration has the following complication rates: infection, 0.7%; perforation, 0.05%; retained POC, 0.5%; and repeat aspiration, 0.5-0.25%.
In D&E and D&X, the skill and experience of the physician are the most important factors in maintaining a low complication rate. Complication rates are low but increase with gestational age. Abortion complications requiring hospitalization include perforation, hemorrhage, infection, retained POC, and inability to complete abortion. Overall rates of hospitalization are 0.6% at 13 weeks of gestation and 1.4% at 20-21 weeks of gestation. Coagulopathy is a rare complication in D&E, occurring in 191 of 100,000 cases.
Avoid complications by obtaining adequate cervical dilatation through using passive dilators in abortions at 14 weeks of gestation and longer and by using double placement of passive dilators at longer than 20 weeks of gestation. Have appropriate instruments available for morbidly obese patients because standard instruments may not be long enough. Match the surgeon's skill and experience to the gestational age of the pregnancy to be terminated. Choose an inpatient setting for patients with severe medical conditions, anemia, placenta praevia (or other abnormal placentation), pelvic masses or large leiomyomas, or vein problems (eg, no intravenous access).
Uterine hemorrhage
Hemorrhage can be caused by atony, retained products, or perforation. Hemorrhage has been defined in a variety of ways, and the need for transfusion is exceedingly rare. If uterine hemorrhage rates include hemorrhage immediately postabortion, uterine atony rates of hemorrhage are as low as 5%. Initial hemorrhage should be evaluated by ensuring complete uterine evacuation.
General anesthesia increases the risk of atony. Blood loss of more than 300 mL in the first trimester is considered excessive. The next steps are typically medical in nature, ie, the use of intramuscular Methergine at 0.2 mg, the use of misoprostol 800 mcg placed rectally. Hemabate is also helpful. Treatment also can include uterine massage medications, removal of retained products, and repair of perforation as indicated. In the past, uterine packing has been used, but this can be accomplished effectively with the intrauterine inflation of a Foley balloon. Balloons of 5 mL can be inflated with 30 mL, or 30-mL balloons can be inflated with up to almost 100 mL of sterile saline. The inflation should correlate with uterine size. Now a Bakri Balloon designed for post abortion or postpartum hemorrhage can be used.
Uterine artery embolization can be used if placenta accreta is encountered, but very few of these procedures have been performed and statistical success rates are impossible to evaluate. If ineffective, hysterectomy should be performed as a life-saving measure.
Damage to cervix
The risk of cervical damage is increased with previous surgery to the cervix or laceration. Damage can be associated with forceful dilation with metal dilators and may be associated with damage to cervical vessels, with hemorrhage and parametrial hematoma formation. Repair damage using a transvaginal approach or laparoscopy/ laparotomy. Prevent damage by avoiding forceful dilation. Passively dilate the cervix using passive dilators and/or prostaglandin analogues. Delay the procedure if adequate dilation is not achieved.
Uterine perforation
Perforation has been estimated to occur in 1 per 250 cases. They are usually fundal and recognized by the provider at the time of the procedure. In a study by Pridmore and Chambers of 13,907 women who underwent outpatient termination of pregnancy, the perforation rate was 0.05% and, in the second trimester, ie, procedures from 13-20 weeks, the perforation rate was 0.32%.[27]
Risk factors for perforation are previous terminations of pregnancy, lower-segment cesarean deliveries, and loop electrosurgical excision procedures of the cervix. The common denominator is thought to be scarring of the internal cervical os.
Fundal perforations only require observation. If the extent of the perforation cannot be determined, if the patient is medically unstable, if the suction was applied at the time of the perforation, or if bowel or fat content was obtained by forceps at the time of a perforation, surgical evaluation of the patient is necessary. The surgical evaluation may be performed by an experienced laparoscopist or by laparotomy.
Perforation can occur with sound, dilators, curette, suction tip, forceps, or passive dilators. Increased risk is associated with previous surgery or laceration involving the cervix, previous uterine surgery, and grand multiparity. In the first trimester, most perforations are in the body of the uterus. Perforation can be recognized when an instrument passes endlessly, heavy or persistent vaginal bleeding occurs, signs of peritoneal irritation appear, or fat or other tissue appears in the specimen. If perforation is made with the sound or dilator, stop the procedure and observe the patient for a minimum of 1 hour. Antibiotic prophylaxis and ultrasonography are options. Reschedule the procedure to be performed in 2-3 weeks. If perforation occurs with suction tip or curette, stop the procedure. Options include observation if the patient is stable and the abortion is complete, laparoscopy if hemorrhage is suspected or the abortion is incomplete, and laparotomy if the patient is unstable.
Retained products of conception
Evaluation of the obtained products of conception at the time of abortion and postabortion uterine scanning have reduced the retained products of conception rate to less than 1% of cases. In one series reported by Hakim, Tovell, and Burnhill of 170,000 cases, only 0.5% incidence occurred in the first trimester.[28] In cases of second-trimester abortions, retained tissue rates are even lower, with rates of 0.2% according to Peterson and 0.5% according to Kafrissen et al.[29]
Cases of delayed bleeding, even after a normal cycle, have been reported. Dilatation and curettage or hysteroscopy are necessary if bleeding is brisker or if the amount of tissue is determined by sonographic evaluation to warrant more extensive procedures.
Endometritis and pelvic inflammatory disease
Infections postabortion are rare, occurring in fewer than 1% of cases. These are usually due to preexisting infections, such as bacterial vaginosis, cervicitis or salpingitis, or a failure of antibiotic prophylaxis.
Fever greater than 102°F (39°C) within 72 hours of the abortion should be considered septic abortion due to retained products. Treatment requires reaspiration followed by intravenous antibiotics (cefoxitin, clindamycin, chloramphenicol, cephalosporin with ampicillin, or penicillinase-resistant penicillin). Fever less than 102°F (39°C) should be treated with reaspiration and oral antibiotics (doxycycline 100 mg bid for 10 d).
The usual criteria should be used for the diagnosis of pelvic inflammatory disease (PID). The Centers for Disease Control and Prevention provides treatment guidelines as well as self-study and ready-to-use modules for clinicians at their Pelvic Inflammatory Disease (PID) Treatment Webpage.
Fatal toxic shock
Rapidly progressing toxic shock due to the endotoxins produced by Clostridia species bacteria has been reported 7 times (for a rate of 1 per 750,000).
Coexistent ectopic pregnancy
Residual positive hCG titers are not uncommon, and clinicians need to be vigilant in their evaluation of persistent positive pregnancy test results to avoid missing an ectopic pregnancy.
Pelvic ultrasonography is the most helpful tool. The presence of significant tenderness during the postoperative examination, a history of continued pain, and the elevation or plateau of hCG titers should raise concern. Coexistent intrauterine and extrauterine pregnancies are observed only in extremely rare cases.
Asherman syndrome
Postabortion uterine synechiae (or adhesions) that can obliterate part or all of the endometrial cavity have been reported. This is thought to be more likely secondary to endometritis than the instrumentation of the uterus, but sharp curetting after the abortion procedure should be avoided to avoid denuding the basal layer of the endometrium.
The diagnosis is made based on hysteroscopy or hysterosalpingogram findings in a patient who presents with postabortion amenorrhea.
Delayed sequelae
Abortion-related hemorrhage due to retained tissue can occur up to several weeks after the procedure. In general, blood loss in excess of that of a normal menstrual period is considered significant and should prompt reaspiration.
Few long-term sequelae of abortions have been documented. Both studies of first trimester surgical and medical abortion found that risks of ectopic pregnancies and spontaneous abortions in future pregnancies were not increased. Some studies have suggested an association between induced abortion and subsequent preterm birth and low birth weight. However, these studies have been retrospective and unable to adequately adjust for confounders also contributing to these outcomes. Although a syndrome of posttraumatic stress has been reported, the literature has not been able to separate the stressors of the patient's social situation that lead to the abortion from the abortion procedure itself.
Although initial studies indicated a greater risk of breast cancer with elective termination than with term birth, a prospective cohort study indicates that no link exists between induced abortion and breast cancer. A prospective study (the Nurses' Health Study II) examined the association between induced and spontaneous abortion and the incidence of breast cancer. Most of the early data has been refuted.
Psychologic consequences of abortion
Generally, the psychological health of the abortion patient parallels her psychologic health prior to seeking an abortion. If the woman needed to have the abortion in secrecy, then long-term psychologic sequelae, such as intrusive thoughts, are more common.
Many studies have actually demonstrated improved psychological well-being after abortion. For the studies that have shown this, the improvement in psychological health is suggested to be more reflective of the patient dealing with the social issues that led her to select abortion.
Sometimes, confusion over normal emotions, such as sadness and grief versus psychological illnesses (eg, depression), seems to occur. The most common feeling experienced after an abortion is that of relief and confidence in the decision. Few women may experience feelings of grief and guilt postabortion, and these feelings usually pass within days to weeks in most cases and do not lead to psychological sequelae. One study demonstrated that the risk for serious psychiatric illness postabortion was 1%, whereas with live birth it was 10%. Considering that more than 1.5 million abortions are performed in the United States each year, if an epidemic of psychiatric sequelae due to the procedure occurred, it would be observed by now.
Many confounding factors are involved in a women's emotional status during the time of her abortion. Relationships, religion, age, social support, and previous psychological stability all play a part.
An entirely new set of circumstances and feelings exist in cases of rape and incest. These are often psychologically complex situations and unique to each case.
Providers can help women through abortions by presenting options and explaining the procedures. Counseling with a trained professional occurs before the abortion. This is a good time to identify factors that might lead to a patient having troubling feelings after the abortion. Some factors are low self-esteem, preexisting or past psychological illness, lack of emotional support, and past childhood sexual abuse. The counselor can then confront these issues before the procedure and help the patient assess specific needs and improve coping strategies.
Give patients information about abortion and postabortion care. Educate patients about birth control options, and discuss when to start birth control postabortion.
Because most terminations of pregnancies in the United States are performed on unintended pregnancies, counseling regarding fertility and contraceptive management are mandatory. In 83% of women, ovulation occurs in the first menstrual cycle postabortion. In first-trimester abortions, contraception should be initiated immediately postoperatively. Intrauterine devices (IUDs) can be safely inserted at the time of the abortion procedure.
For patient education resources, see Pregnancy Center as well as Abortion, Miscarriage, and Dilation and Curettage (D&C).