AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

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

• Since the 1973 decision, approximately 1.3-1.4 million abortions have been performed annually in the United States.
• Abortion is one of the most common medical procedures performed in the United States each year. 
• More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives. 
• Worldwide, some 20-30 million legal abortions are performed annually, with another 10-20 million abortions performed illegally (see The Alan Guttmacher Institute). Illegal abortions are unsafe and account for 13% of all maternal mortality and serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
• In spite of the introduction of newer, more effective, and more widely available contraceptive methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these pregnancies, approximately half end in elective terminations.
• Each year in the United States, almost 3% of all reproductive-aged women terminate their pregnancies. While women of every social class seek terminations, the typical woman who terminates her pregnancy is young, white, unmarried, and poor.

Legalization of Abortion

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

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

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

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

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

Before Roe v Wade

Before the 19th century, most US states had no specific abortion laws. The provisions of British common law took precedence, and women had the right to terminate a pregnancy prior to viability. 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.

The first US federal law on the subject was the notorious Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception to suppress the circulation of "obscene" materials. From 1900 until the 1960s, abortions were prohibited by law. However, the Kinsey report noted that premarital pregnancies were electively aborted, and public and physician 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, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain contraceptives from their provider.

Roe v Wade

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

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

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

Viability determinations

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

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

Parental consent

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

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

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

Intact dilation and extraction

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

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

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

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

Providers

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

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

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

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

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

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

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

Pathophysiology

Surgical termination

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

Abortions performed prior to 9 weeks from the last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. From 9 weeks until 14 weeks, an abortion is performed by a dilatation and suction curettage procedure. After 14 weeks, surgical abortions are performed by a dilatation and evacuation procedure. After 20 weeks of gestation, abortions can be performed by labor induction, prostaglandin labor induction, saline infusion, hysterotomy, dilatation and extraction, or intact dilatation and extraction. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.

Medical termination

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

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

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

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

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

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).

See Medscape's CME course Previous Medical vs Surgical Abortion May Not Increase Risk for Adverse Outcomes.

Frequency

United States

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

In 1996, approximately 20 women for every 1000 women aged 15-44 years had an abortion, and for every 1000 live births, approximately 325 abortions were performed. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social milieu of abortion have led to more women seeking terminations later in pregnancy. For the current facts regarding abortions performed in various states at various times in the pregnancy.

In 2000 only 12.5% of abortions were performed in the second trimester of pregnancy (CDC), of which almost all between 13 and 20 weeks were surgical abortions, the others being performed by labor induction.

International

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

Mortality/Morbidity

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

Race

In 1996, of the women who obtained legal abortions, 59.1% were white, 2% were black, and 5.7% were of other races (of the other, 16.1% were of Hispanic origin).

Age

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

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

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

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

Physical

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

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

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

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Preabortion workup
• • Pregnancy tests are used to confirm the presence of a pregnancy, and home tests are reliable enough that their results can be accepted in some cases.
  • Hemoglobin (Hb) or hematocrit (Hct) levels are always assessed. A full CBC count is optional but may be indicated if abnormal findings are detected with the Hb or Hct test.
  • STI screening typically includes a gonorrheal culture (GC) or chlamydial test (CT), and targeting those aged 25 years and younger is considered appropriate. Screening for other STIs, such as syphilis or HIV disease, is usually prohibitively expensive; however, patients with positive results from the GC or CT should be offered these tests.
  • Rh typing is always performed. ABO typing is optional.
• Use of human chorionic gonadotropin titers
• • Human chorionic gonadotropin (hCG) titers are helpful in performing very early terminations, to establish the completeness of an abortion postoperatively in cases of persistent positive results from a urinary pregnancy test, or to establish the presence of an ectopic pregnancy. Prior to a medical abortion, ruling out ectopic pregnancy is mandatory. In medical abortion protocols, they can also be used to establish the arrest of viability of a pregnancy or to establish the completeness of a medical abortion.
  • Titer resolution is different between surgical and medical abortions. The titer should decrease to approximately 64% of its preabortion value within 24 hours of misoprostol being administered in medical abortion protocols. By 2 weeks, the titers should have dropped 99%.
  • If an abortion is being performed prior to 5 weeks from the LMP, obtaining titer values preoperatively can be very useful. Managing most abortion procedures without obtaining an hCG titer is within the standard of care.
• Wet preparations
• • Vaginal wet preparations, pH testing, and/or urine dipstick analysis are usually performed for standard indications.
  • If a woman is discovered to have a concomitant infection, it may require treatment before she has an abortion.

Imaging Studies

• Ultrasonography is invaluable but not always used in first-trimester terminations. The standard of care demands that second-trimester terminations be evaluated preoperatively with sonography. Documenting uterine abnormalities is important because failed terminations can occur in patients with double uterus or ectopic pregnancies.
• • First-trimester sonography: The results of the examination are what is typically expected for a first-trimester screening examination. The focus is on fetal number, the size and nature of the gestational sac, the placental location, the uterus, and the ovaries. Document the presence and nature of a yolk sac.
  • Second- and third-trimester sonography: For second- or third-trimester abortions, performing an ultrasound preoperatively is the standard of care. Conduct these examinations like other second-trimester screening examinations. If anomalies are detected, women should be offered a referral for targeted examinations that can delineate specific fetal disease conditions. Not unusually, women decline further investigation if their abortion decision does not hinge on the specific findings.

Other Tests

• Papanicolaou tests (Pap smears) are optional specifically prior to the procedure, but patients should be informed of their need for Pap smears as part of their postabortion contraceptive care.
• Genetic testing of an abnormal 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 pre-arranged and may be expensive.

Histologic Findings

Pathologic analysis of tissue is typically performed for documentation purposes, but visual inspection of the products of conception postprocedure is mandatory. Washing the blood clots off the tissue obtained prior to visual inspection is helpful, and the presence of villi can be detected more reliably after back-lighting the specimen. In cases in which very little tissue is obtained, the use of colposcopy may reveal villi. Pathologic confirmation should be available within 24 hours if an ectopic pregnancy is suggested or within a week to 10 days if no pathology is suggested. Many fetal anomalies can be detected upon anatomic inspection of the fetus, but only intact procedures or induction of labor reliably offer a fetal specimen that can be evaluated adequately.

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.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Once the pregnancy has been confirmed, gestational age has been established, and the patient has decided to abort, the procedure offered typically reflects the patient's stage of gestation. Early abortions can be accomplished medically or surgically, but most facilities do not have the protocols established or personnel with the technical ability to offer medical abortions. Therefore, most abortions are performed surgically.

• Preoperative care of patients undergoing surgical abortion
• • Women often travel far for their abortion procedure and feel comfortable completing the preoperative preparation in a short office visit. In states where laws require waiting periods, this can be done in stages.
  • The assessment process involves only a targeted history, physical examination, laboratory work, and ultrasonographic evaluation (including dating of the pregnancy, if indicated) followed by a counseling session.
  • Second-trimester pregnancy preparation is more difficult. Preparing the cervix in less than 24 hours is almost impossible, but the basic assessment process is identical.
  • Ultrasonographic examinations should involve a more extensive examination, looking specifically for obvious fetal anomalies (see Imaging Studies).
  • Some centers also offer either intracardiac, intrathoracic, or an intra-amniotic injection of digoxin (1 mg), which ceases fetal cardiac activity and has very low transplacental medication leakage; therefore, it has been shown to be safe for the mother. Potassium chloride may be used as well, but complication rates have been higher. This ensures fetal death prior to fetal expulsion, regardless of the method of second-trimester abortion chosen.
• Abortion counseling
• • Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing to term, information and options for the technique of the abortion procedure, and, finally, information regarding a contraceptive decision. The risks and benefits of both medical and surgical abortions should be reviewed.
  • The counseling process is aimed primarily at the woman herself but may also include other persons she chooses to be involved. Studies indicate that males are involved in more than 40% of the decisions, but only scant research has been performed on male involvement in the process. Some women can reach a decision quickly; others take longer to decide. The counseling process should include referrals for those who need ongoing support.
  • Of utmost importance is to ensure that the patient has had enough time to consider her options and that she is not being coerced into her decision.
  • Many strategies can be used in the counseling session. Open-ended questions bring out issues that are pertinent to the woman and encourage meaningful exchange of dialogue. The patient's emotions should be validated, and the counselor should encourage the client to explore her feelings in more depth. Health care providers and counselors may not have the time or expertise to devote themselves to lengthy sessions, and not all women are able to complete the process in a day if these issues need to be explored before the abortion procedure.
  • Some state laws may apply to the counseling process. Some states have mandatory waiting times between the information session and the actual abortion, other states require family or parental notification, and some states mandate that certain subjects be covered. These laws are controversial because the validity of the materials may be outdated before the state has made any changes to the regulations. In some cases your local institution or funding agency may have rules regarding counseling. Usually, laws directed toward the providers also exist. Providers have an obligation to find out about their local laws and to comply with them.
• First- and second-trimester medical abortion
• • First-trimester terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or mifepristone with or without misoprostol. Other prostaglandins are used outside the United States. The simplest and most effective regimens are mifepristone and misoprostol together.
  • Medical abortions are indicated for women who consent to a medical abortion but are also willing to undergo a surgical abortion if the medical abortion fails. Gestational age for the FDA-approved protocol is 49 days, but many protocols, including up to 63 days from the LMP, are in the literature and in widespread clinical practice. Also, literature documenting the safety of medical abortion protocols at 11-13 weeks is accumulating. Only scant reports exist of continuing pregnancies after misoprostol, but the current data do not suggest a teratogenic action of misoprostol exposure during pregnancy.
  • Contraindications to medical abortion vary depending on the regimen selected. Contraindications to mifepristone include serious medical problems, such as cerebrovascular or cardiovascular disease, severe liver, kidney or pulmonary disease, preoperative anemia (<10 mg/dL), undiagnosed ectopic pregnancy, allergies, contraindications to prostaglandin use, active uterine bleeding, or large uterine leiomyomata.
  • The mifepristone/misoprostol appointment schedule is as follows:
  • • On day 1, mifepristone, typically 200 mg (600 mg PO is FDA regimen), is administered in the office.
    • On day 2 or day 3, the misoprostol (800 mcg vaginally or 400 mcg PO) is administered at home. The FDA regimen is administering the medication on day 3 with a 4-hour observation period after insertion; however, if the patient is bleeding, the misoprostol may be used immediately, as soon as 8 hours after the mifepristone. Vaginal-moistened, rectal, sublingual, and buccal dosing are all possible.
    • The patient returns to the office for a follow-up 7 days after the medical abortion to determine if the abortion has been completed. The amount of bleeding does not determine procedure completion.
    • Up to 43% of intersubject plasma concentration variability may occur with oral dosing and both food and antacids interfere with absorption and bioavailability.
    • Vaginal dosing reaches lower peak levels, but the levels are more sustained.
    • Tissue is not typically sent for confirmation.
    • After all routes of administration, sustained uterine contractions develop 1.5-2 hours after dosing. 
  • • If the abortion is not complete, repeat misoprostol is administered or the patient may undergo a surgical abortion.
  • The methotrexate/misoprostol regimen is similar, as follows:
  • • Methotrexate is injected on day 1.
    • On days 6-7, misoprostol is taken at home vaginally, and the patient returns to the office on day 8 to determine if the abortion has taken place. Misoprostol can be repeated and the patient monitored, or surgical abortion may be completed.
• Prostaglandin-induced second-trimester abortion
• • Prostaglandin can be administered vaginally, orally, or via extraovular or intra-amniotic infusion. The intra-amniotic route was associated with greater rates of uterine rupture, although rarely, and has been abandoned largely in favor of the safety and technical ease of oral or vaginal administration.
  • Dosing regimens of 50-800 mcg have been studied with a wide range of induction schedules. About 98% of patients should deliver within 24 hours of doses 200-600 mcg and beginning and following doses are adequate.
  • In a recent comparison study by Perry of intra-amniotic 15-methyl-prostaglandin F2-alpha and intravaginal misoprostol, the mean evacuation time was slightly less in the intra-amniotic group and the rate of success by 24 hours was higher in the intra-amniotic group. The total complete abortion rate and incidence of severe effects were similar in both groups.
  • After many regimens have been evaluated 400 mcg probably has greater success with tolerable side effects. Increasing dosing increases side effects without increasing efficacy. Most services use vaginal administration at 12-22 weeks' gestation. Every 3 hours has faster delivery times than every 6 hours, although every 6 hours is often used in the United States. Many protocols begin with 600 mcg first to enhance cervical ripening than decrease dose. Optional additional treatments included placental surgical removal and fetal extraction.
  • Rates of retained placenta vary from 10-60%. Patients with prior cesarean delivery have been treated safely but absolute risk of rupture is uncertain.
• Adjunctive methods of treatment
• • Fetocide can be accomplished with intra-amniotic or intrafetal digitalis. This is easily performed and probably extremely safe for the mother. Psychological implications for the mother and provider are poorly understood. Time from intra-amniotic instillation to death of fetus is uncertain and care should still be taken to not violate partial-birth abortion laws if fetal extraction becomes necessary.
  • Laminaria: If laminaria have been used for cervical preparation, the time to delivery is typically hastened.
• Saline-induced abortion
• • Twenty years ago, saline-induced abortion was the only viable means of aborting a mid–second-trimester pregnancy, and most of the literature regarding this technique is from that era.
  • The process was long, laborious, had some potentially serious adverse effects, and has been abandoned for the greater maternal comfort offered by the dilatation and extraction procedures that subsequently have been developed. However, dilatation and extraction procedures are risky in the hands of inexperienced providers or providers who do not perform the procedures often enough to maintain competency.
  • In these circumstances, the saline-induced abortion can be safely used.

Surgical Care

Documentation is an important part of the surgical procedure. Preoperatively prepared standard operative reports are the standard of care and should include documentation of several important features, including the patient's anatomical assessment (including uterine size), the procedure and instruments used (including the size of the dilators and the cannula used), the amount of blood loss, and the amount of tissue obtained.

• 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.
  • Cases that might find cervical preparation helpful include uterine abnormalities and history of caesarian delivery.
  • Prior to insertion, the cervix is prepared with Betadine, but sterile technique has been shown to be as safe. Laminaria insertion is simple, often requiring a single-toothed tenaculum to stabilize the cervix and no anesthesia. For cases in which several laminaria must be inserted, 12 mL of lidocaine administered paracervically can provide comfort. The patient must understand that laminaria insertion is the beginning of the abortion procedure. Pregnancies have been safely carried to term after laminaria insertion and removal, but late-onset intrauterine infection or chorioamnionitis is a concern. Counseling is used to be sure the patient understands her risks once she starts the dilatation process.
  • Failure to dilate the cervix is not common, but if no dilators (the smallest is 3 mm) or laminaria can be admitted, this is the diagnosis. Rare cases exist in which the cervix is so scarred, mostly from previous pregnancies or deliveries, that the os cannot be viewed; the patient may be advised to have dilation with medical preparation such as vaginal misoprostol 200-800 mcg 2-6 hours preoperatively, but be aware that the patient may spontaneously go into labor or have a medical abortion. Waiting until the patient is further in pregnancy is an option, as is dilating while watching with sonographic control.
• Intraoperative care of patients undergoing surgical abortion
• • Most patients having an early termination of pregnancy can have their abortion performed under "vocal sedation" (ie, talking the patient through the procedure) and local sedation. Most patients do not require intravenous access for medication.
  • If heavy sedation is selected, then intravenous fluids with lactated Ringer solution or half isotonic sodium chloride solution is suitable, at rates appropriate for the patient's age and weight.
  • If a patient receives intraoperative sedation, appropriate monitoring includes vital sign assessment, assessment of the patient's degree of sedation and responses, and assessment of the patient's pulse oxygen level. Appropriately trained staff should be present as well.
• First-trimester surgical abortion
• • Early terminations are performed with little cervical dilatation and using a hand-held syringe or a small-bore cannula attached to a suction machine. Abortions performed with a syringe are referred to as manual aspirations. Some authors still call them menstrual extractions, from the days when abortion was more stigmatized and women did not want the procedure referred to as an abortion. Those performed with the suction generated by a vacuum aspirator are referred to as a vacuum aspiration. Both procedures take only a few minutes.
  • Single-toothed tenaculums are used to grasp the cervix after it has been prepared with Betadine. Local anesthetic is administered in a paracervical fashion. The agent used is usually 1-2% lidocaine or 1% Nesacaine. No epinephrine is necessary. The local anesthetic takes effect rapidly, and studies of the exact route of administration (eg, several spots around the cervix or at the 3- and 9-o'clock positions) have not shown large differences in efficacy.
  • For gestations of 6 weeks or less, cannulas of 3-6 mm can be used. For gestations of 7-9 weeks, 5- to 9-mm cannulas are used. The suction cannulas can be soft or rigid or straight or bent, and experienced providers can use either type interchangeably. Both suction syringes and suction machines generate 60-70 mm Hg of pressure. Performing procedures at lower levels of suction prolongs the procedure and, therefore, increases bleeding and patient discomfort.
  • The amount of tissue obtained correlates with the stage of gestation and the fetal number. The amount of bleeding can be very slight, 5-25 mL for very early terminations, or as heavy as 100-250 mL. More than 200 mL of blood loss is usually indicative of uterine atony. Cervical lacerations increase the amount of blood lost.
  • Intravenous sedation with Versed (2.5-5 mg) can be performed, and rapidly acting narcotics can be added for pain relief. Others have had success with sublingual diazepam, and intramuscular Toradol (ketorolac tromethamine) can be used.
  • Abortions in the late period of the first trimester are performed with or without preoperative cervical dilatation with laminaria or misoprostol. If a woman is multiparous, no preoperative dilatation is usually necessary, although procedures under local anesthetic are more comfortable if the cervix has been prepared.
  • Sounding should be performed with the cannula to protect the uterus against perforation. The actual evacuation is performed by applying suction to the syringe or via the machine. The completeness of the procedure is ensured by the feel of the uterus against the instrument, the sound of the uterine curettage, and the appearance of bubbles in the cannula. Sonographic confirmation of completeness is helpful in some cases. The procedure takes a few minutes to complete, and the estimated blood loss should be minimal (5- to 10-mL range for very early abortion and 50- to 100-mL range for later procedures).
  • Tissue inspection for completeness is an essential part of the procedure.
• Dilatation and curettage
• • This specifically is a term that is usually applied to a diagnostic gynecological procedure or the treatment of an incomplete abortion.
  • The procedure is usually accomplished with similar dilatation procedures, but uterine emptying is accomplished with a sharp metal curette. These curettes are more dangerous than the flexible or rigid plastic devices, which are used in the suction procedures, and are not recommended for abortion procedures.
• Second-trimester dilatation and evacuation
• • Dilatation and evacuation is the safest and most common method of second-trimester termination for experienced providers. These procedures are accomplished with preoperative preparation similar to first-trimester preparation; however, the dilatation must be accomplished over hours and, in some cases, days. Dilatation and evacuation is not a risk factor for subsequent midtrimester pregnancy loss or spontaneous preterm birth. See Preoperative care of patients undergoing surgical abortion.
  • The procedure requires the cervix to be dilated to 2-3 cm, admitting at least a No. 16 Hegar dilator or a 53F dilator. The cervix is grasped with a single-toothed tenaculum after Betadine preparation. The procedure is accomplished using a combination of suction curettage and manual evacuation of the fetus and placenta. Ultrasonic guidance is valuable, and some providers use manual palpation of the fundus to guide the forceps used for evacuation. The forceps are used most carefully in the lower uterine segment. The types of forceps used are Soper, ring, or packing forceps, with Soper forceps being the most useful. Uterotonics can help push the products of conception toward the internal os to facilitate the process.
  • The procedure is longer and more uncomfortable than a first-trimester procedure, but many patients can comfortably go through the procedure with local anesthesia. Blood loss for these procedures is 100-350 mL.
• Dilatation and extraction
• • This procedure is accomplished by cervical preparation similar to cases of dilatation and evacuation, but the fetus is removed in a mostly intact condition. The fetal head is made of cartilage and is able to be collapsed after the contents are evacuated so that it may pass through the cervix.
  • Current laws prohibit performing this technique on a live fetus and the definition of the law should be reviewed and it should be documented that this technique occurred. 
• • Very few providers perform the procedure. It is usually reserved for cases of maternal medical complications or fetal abnormalities.
  • With an intact fetus, the family may hold their baby and have time to say good-bye as part of the grieving process. Reconstituting the fetal head with a jellied substance can restore fetal anatomy.
  • The procedure has also been referred to as intact dilatation and extraction and has been called partial-birth abortion by abortion opponents.
• Induction of labor
• • Most physicians have experience with the standard Pitocin protocols for labor induction, and these can be used in the second trimester of pregnancy.
  • Premature rupture of membranes is one indication for this method.
  • Research generally indicates better success with prostaglandin methods, protocols using 200-600 mcg every 3 hours usually work the best. Special concerns are in cases of prior cesarean delivery.
• Hysterotomy
• • Hysterotomy is reserved for very few cases. The presence of large uterine leiomyomata has been an indication for hysterotomy in the performance of an abortion, and in the past, placental previa was another indication (recent reports have shown that a dilatation and evacuation procedure can be performed safely in some of these cases).
  • The uterine segment is never developed well enough to place the incision there, so virtually all hysterotomies must be performed by classic uterine incisions.
• Hysterectomy
• • Very few indications exist for the use of hysterectomies to terminate pregnancies.
  • The extrauterine vasculature that develops in pregnancy makes hysterectomy more dangerous, and the incidence of hemorrhage and complications rises.
• Surgical sterilization
• • Bilateral tubal ligation via minilaparotomy, tubal fulguration, or tubal device occlusion is easily performed at the time of first- or second-trimester abortion of pregnancy.
  • Failure rates are high because of the enlarged tubal structure and lumen, but the magnitude of risk is not well established.

Consultations

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

Diet

• Patients may eat a regular diet.

Activity

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

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

Drug Category: Prostaglandins

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

Drug Category: Local anesthetics

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

Drug Category: Antiprogesterones

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

Drug Category: Antimetabolites

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

Drug Category: Uterotonics

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

Drug Category: Ergot alkaloids

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

Drug Category: Sedatives

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

Drug Category: Antiemetics

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

Drug Category: Antibiotics

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

Drug Category: Immune globulins

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