AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Therapeutic abortion is defined as the termination of pregnancy before fetal viability in order to preserve maternal health. In its broadest definition, therapeutic abortion can be performed to (1) save the life of the mother, (2) preserve the health of the mother, (3) terminate a pregnancy that would result in the birth of a child with defects incompatible with life or associated with significant morbidity, (4) terminate a nonviable pregnancy, or (5) selectively reduce a multifetal pregnancy.

The vast majority of abortions performed in the United States are elective. Pregnancy-related conditions that threaten maternal life are rare and difficult to define precisely. The decision to terminate a pregnancy for medical indications is generally a multidisciplinary decision including the obstetrician, a specialist in the disease entity in question, the patient, and the patient's family.

The methods used to terminate pregnancy vary according to gestational age, the indication for termination, and medical and surgical considerations relevant to the mother. Abortion can be accomplished by surgical or medical means.

Most of this article is devoted to the discussion of indications for therapeutic abortion and medical methods for termination of pregnancy. An in-depth discussion of surgical abortion is covered in Surgical Management of Abortion.

History of the Procedure

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. 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.

In the United States, legislation regarding abortion has varied with the times. Before 1800, no statutes addressed the subject of abortion. The first antiabortion legislation appeared in the 1820s; the preservation of pregnant women's health was the motivating force. 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.

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.²⁰ In the United States, the legalization of abortion by Roe v Wade in 1973 upheld the fundamental right of a woman to determine whether to continue her pregnancy.

Problem

US statistics indicate that the vast majority of abortions are elective. Therapeutic abortion is rare. 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.

Frequency

Approximately 3-5% of all newborns have a recognizable birth defect. According to Cunningham and MacDonald¹⁰, the suggested causes of fetal anomalies are as follows:

• Genetic (ie, chromosomal) (20-25%)
• Fetal infections (3-5%)
• Maternal disease (4%)
• Drugs/medications (<1%)
• Unknown (65-70%)

Medical complications during pregnancy encompass a wide array of medical problems, to include the following:

• Hypertensive disorders
• Diabetes mellitus
• Hematologic disorders
• Cardiovascular diseases
• Thromboembolic disorders
• Thyroid and parathyroid diseases
• Pituitary disorders
• Adrenal disorders
• Renal diseases
• Hepatic diseases
• GI tract disorders
• Pulmonary diseases
• Infectious diseases
• Neurologic diseases
• Psychiatric disorders
• Malignancies

The diseases tend to occur in frequencies compatible with those of nonpregnant age-matched women. Providing an in-depth review of this wide array of medical problems is beyond the scope of this article.

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:

• Cervical cancer (1 case per 2200 pregnancies)
• Breast cancer (1 case per 3000 pregnancies)
• Melanoma (0.14-2.8 cases per 1000 pregnancies)
• Ovarian cancer
• Thyroid cancer
• Leukemia (rare)
• Lymphoma
• Colorectal carcinoma (0.10-1.0 cases per 1000 pregnancies)

Clinical

Patients in need of therapeutic termination of pregnancy can be identified at any gestational age; however, the consideration of therapeutic abortion is generally limited to pregnancies at 24 weeks' gestation or less. Many patients are in the second trimester of pregnancy because of the timing of fetal assessment tools (eg, triple screen, amniocentesis, ultrasound).

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The indications for therapeutic abortion, in its broadest definition, are as follows:

• To save the life of the pregnant woman
• To preserve the health of the pregnant woman
• To terminate a pregnancy that would result in the birth of a child with defects incompatible with life or associated with significant morbidity
• To terminate a nonviable pregnancy
• To selectively reduce a multifetal pregnancy

Therapeutic abortions to save the life of the mother or to preserve the health of the mother are rare events. The decision should be based on the collaborative agreement of a multidisciplinary team. At minimum, the team should consist of the patient, the obstetrician, a specialist with knowledge of the disease in question, an expert in genetic counseling, and a neonatologist. Additional members may include spiritual counselors, nurses, psychologists/psychiatrists, intensive care specialists, ethicists, and family members.

The decision to terminate the pregnancy includes consideration of the effect of the pregnancy on disease outcome, the effect of treatment on fetal outcome, the gestational age of the pregnancy, the level of attachment of the patient to the pregnancy, the desires of the patient and the father, and the availability of family resources/support. This complex situation requires thought and excellent communication among the involved parties regarding the short- and long-term consequences of the decision to abort or continue the pregnancy. The decision must be individualized for each patient. There must be an inherent acceptance of the subjective nature of decisions made in this area. The clinical situations may be rare, and clinical data available may be anecdotal, incomplete, and/or inconclusive.

Commonly accepted medical indications for therapeutic termination of pregnancy include severe hypertensive vascular disease, cardiac disease with cardiac decompensation, and certain malignancies.

Malignancy

Cervical cancer is the most common malignancy affecting pregnant women. Invasive cervical cancer is treated with surgery or radiation; both treatment modalities result in fetal death for the previable fetus. Delay of therapy is the only option that allows fetal salvage in this setting. Treatment delays to allow fetal maturation have been successfully attempted in stages IA and IB. Treatment delays for advanced disease (stages IIB-IV) are controversial. All decisions regarding delay must be individualized and must consider other factors that affect the prognosis (eg, HIV status).

The prognosis for patients with breast cancer is not adversely affected by continuation of pregnancy. The decision to terminate a pregnancy complicated by breast cancer in the first and second trimesters is determined by the degree to which the pregnancy impairs effective treatment and whether treatment presents a risk to the fetus.

The prognosis for patients with melanoma is not improved by therapeutic abortion. Metastatic spread of melanoma to the placenta and fetus has been reported but is very rare. This type of spread has also been reported with lymphoma, leukemia, breast cancer, lung cancer, and stomach cancer and should be addressed when counseling at-risk patients.

Fetal conditions

A pregnancy in which the fetus has defects that are either incompatible with life or associated with significant morbidity can be an indication for therapeutic abortion. The number of fetal conditions that can be identified during pregnancy is always expanding because of improvements in technology available for antenatal diagnosis. The following fetal conditions are identifiable:

• Chromosomal disorders
• X-linked disorders
• Metabolic disorders
• Neural tube defects
• Structural anomalies associated with exposure to teratogens
• Structural anomalies of multifactorial or unknown etiology

Multifetal pregnancies

Multifetal pregnancies are associated with high fetal morbidity and mortality rates. In this setting, morbidity and mortality are associated with high rates of preterm delivery and growth retardation. Preterm birth rates at less than 33 weeks' gestation are 8 times higher for twins and 24 times higher for triplets compared with singleton pregnancies. Each additional fetus in a pregnancy reduces the length of the pregnancy by approximately 3.6 weeks. After birth, the mortality rates for infants born in multiple pregnancies remain elevated from birth to age 5 years, even after controlling for growth restriction.

Multifetal reduction has been shown to reduce the risk of preterm delivery for the remaining fetuses. However, the incidence of prematurity in reduced pregnancies appears to remain higher than in spontaneous pregnancies of the same fetal number. An overall reduction in morbidity-improved survival rates occurs in reduced pregnancies compared with pregnancies in which reduction is not performed.

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Adequate evaluation of uterine size is mandatory. Physical examination may be inadequate for uterine sizing because of the following factors:

• Obesity
• Patient apprehension with voluntary guarding
• Presence of a retroverted uterus
• Firm abdominal musculature
• Uterine leiomyoma

Obtaining ultrasound confirmation of gestational age is common practice when a therapeutic abortion is planned. Anticipating potential complications associated with the abortion procedure is important.

Consider anatomic problems that may contribute to technical difficulties during an abortion. Make every attempt to minimize complications because of their impact on a patient who may already be compromised because of an underlying disease. A small, stenotic, or scarred cervical os may impair the cervical dilation necessary for safe surgical terminations of pregnancy. A long vaginal canal may also make the use of surgical instruments difficult, and labor induction may need to be considered.

The presence of uterine leiomyomas may make uterine sizing erroneous and the dilation of the cervix difficult or impossible and may contribute to increased blood loss at the time of either surgical or medical abortion procedures.

Abnormal placentation (ie, placenta previa, placenta accreta, placenta percreta) is associated with high parity and previous uterine surgery. This issue must be addressed carefully. Abnormal placentation requires surgical intervention with careful consideration of the anticipated amount of blood loss. The selected surgical abortion method should cause minimal blood loss and be of limited invasiveness. For certain patients, special interventions, such as embolization using interventional radiology techniques, may be needed on a standby basis.

The presence of uterine anomalies (eg, uterus didelphys, unicornuate uterus, septate uterus) may make entering and emptying of the uterus complicated. If surgical abortion is selected, ultrasound guidance during the procedure may be helpful. The abortion of a multiple gestation may make surgical abortions more challenging, and the use of ultrasound guidance is helpful. Data are not available for the use of medical abortion in this setting.

Careful consideration of the choice of anesthesia must be based on the medical, psychiatric, and emotional condition of the patient. Consultation with anesthetists, medical specialists, and psychiatric specialists may be necessary to determine the best choice of anesthesia for an individual patient. In general, local anesthesia affords the greatest safety. General anesthesia for surgical abortions is associated with greater overall risk of anesthesia complications and hemorrhage.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Absolute contraindications to termination of pregnancy are virtually unknown. In the face of significant maternal risk of medical or psychiatric morbidity/mortality, continuation of pregnancy usually presents far greater risk than termination of pregnancy. A particular type of abortion procedure or the timing of abortion may be contraindicated based on the current medical, surgical, or psychiatric condition of a patient. For example, medical abortion is contraindicated in patients with the following conditions:

• Clotting disorders
• Severe liver diseases
• Renal diseases
• Severe cardiac diseases
• Long-term steroid use
• Medical conditions or use of medications that preclude the use of medical abortion medications
• Adrenal failure
• Undiagnosed adnexal masses
• Ectopic pregnancy (except with use of methotrexate)

Medical abortion should be performed with caution in patients with the following conditions:

• Severe anemia
• Poorly controlled bowel disease (may cause an exacerbation of symptoms)

Surgical abortion is contraindicated in patients with the following conditions:

• Hemodynamic instability
• Profound anemia
• Profound thrombocytopenia

Instillation abortion techniques are contraindicated in patients with the following conditions:

• Active pelvic infections
• Inability to tolerate a solute load (saline only)
• Asthma, glaucoma, epilepsy, hypertensive cardiovascular disease, pulmonary hypertension (prostaglandin F_2a [PGF2a])
• Fetal demise (saline, urea)

The rare patient with placenta accreta or placenta percreta may require consideration of laparotomy with hysterotomy/hysterectomy despite the increased morbidity and mortality risks associated with these procedures.

Multifetal reduction of pregnancy has inherent risks of rupture of membranes, preterm labor, preterm delivery, and infection, which must be balanced against the benefits of the procedure. Special circumstances, such as the selection of the presenting fetus for reduction, may present a greater risk of loss of the entire pregnancy and must be considered in the risk-benefit analysis.

In patients with significant medical or surgical risk, the choice of abortion procedure must be individualized. All abortion methods may present relative or absolute contraindications for some patients. In the face of limited or absent data for a specific clinical situation, the choice of abortion method is based on the best collective medical judgment of the team of clinicians caring for the patient.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Lab Studies

• Surgical abortion: Pregnancy test, CBC count, and blood typing are the minimum laboratory studies required for surgical abortion.
• • A pregnancy test is required to exclude non–pregnancy-related causes of secondary amenorrhea.
  • A CBC count is required to identify patients with significant anemia, who are at risk if excessive blood loss occurs. Transfusion may be needed, particularly in second-trimester abortions. Patients with severe anemia are best treated in a setting where transfusion is available.
  • Blood typing is required so that Rh-negative women can be identified and given RhoGAM to prevent Rh sensitization in subsequent pregnancies.
  • Screening for common sexually transmitted diseases (STDs) should be addressed in geographic areas of high prevalence, in age groups at high risk (ie, <25 y), and in at-risk groups (eg, those with histories of STDs, multiple sex partners, substance abuse).
  • Additional laboratory testing is dictated by the medical history and physical examination findings.
  • • Coagulation studies are indicated for patients with conditions such as a history of coagulopathy, hematologic malignancies, hemorrhage with previous surgical procedures, petechiae, bruising, and hepatosplenomegaly.
    • Liver function tests are indicated for patients with conditions such as hepatitis, alcohol abuse, metastatic cancer, hepatomegaly, and jaundice.
    • Renal function tests are indicated for patients with conditions such as renal disease, recurrent urinary tract infections, oliguria, hematuria, and proteinuria.
• Medical abortion: Pregnancy test, CBC count, and blood typing are the minimum laboratory studies required for medical abortion.
• • In cases of methotrexate use, platelet count, electrolytes, liver function tests, and BUN and creatinine levels are required. Thrombocytopenia and chemical hepatitis are rare (in the doses used for medical abortion) but known complications of methotrexate use.
  • Electrolyte assays are necessary in patients who develop significant vomiting associated with the use of medical abortion techniques.
  • See Surgical abortion for other laboratory studies and indications for their use.
• Instillation techniques
• • A pregnancy test and CBC count are required; see Surgical abortion for indications.
  • Platelets, coagulation studies, liver function tests, and renal function tests are recommended as baseline testing for instillation methods because of the risk of coagulopathy, vomiting, and diarrhea associated with this method.
• Selective reduction: No specific laboratory tests are required; however, specific laboratory tests may be ordered for individual patients based on history and physical examination findings.

Imaging Studies

• Baseline ultrasounds are routinely used in medical abortion, surgical abortion, and instillation abortion techniques.
• A chest radiograph may be indicated depending on history and physical examination findings.

Other Tests

• Chorionic villus sampling or amniocentesis for fetal chromosome evaluation may be indicated depending on maternal age, obstetric history, family history, or ultrasound findings.

Diagnostic Procedures

• Specialized testing is needed for certain indications.
• • For example, fetal umbilical cord blood sampling is indicated when fetal blood must be obtained for diagnostic testing.
  • An ECG may be indicated depending on maternal age, history, physical examination findings, and anesthesia requirements.
  • 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.

Histologic Findings

Collecting tissue for pathologic examination is generally impossible for first-trimester medical abortion and is not part of the recommended protocol. Collection of tissue for pathologic examination for surgical abortion and second-trimester medical abortion is routine.

The obligation to collect tissue from abortion procedures is determined by state abortion regulations and must be addressed in a state-by-state manner. The need to collect tissue for diagnosis of fetal anomalies is addressed on a case-by-case basis. The same state and federal statutes apply for medical and surgical abortions despite the fact that the laws were written for surgical abortion.

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Medical therapy

Medical therapy includes instillation techniques and medical abortion techniques.

Instillation techniques

Instillation agents include hypertonic saline, hypertonic urea, and prostaglandin. All instillation agents function by inducing uterine contractions, which end in the evacuation of the uterine contents.

The instillation technique is performed in a similar fashion for all agents. Selected patients are in the second trimester of pregnancy. The patient empties her bladder, and the abdomen is cleansed with an antiseptic solution. An amniotic fluid pocket can be identified using ultrasound. Alternatively, the skin can be anesthetized using a local anesthetic. An 18-gauge spinal needle is transabdominally introduced into the amniotic sac. Free flow of amniotic fluid is confirmed. (Fluid can be tested with pH paper; urine is acidic, amniotic fluid is basic.) The abortifacient is injected, as follows:

• Hypertonic saline: Inject 40 g (ie, 200 mL 20% saline).
• Hypertonic urea: Inject 80 g in 5% D5W.
• PGF2a: Inject 20-40 mg. Use a test dose of 2.5-5 mg, followed by 17.5-35 mg.

In instillation techniques, the cervix is made inducible by the use of passive dilators (laminaria, Dilapan inserted in cervix) or use of intravaginal prostaglandins (eg, misoprostol, prostaglandin E₂ [PGE2] suppositories).

Medical abortion techniques

Medical abortion agents include (1) mifepristone and misoprostol, (2) methotrexate and misoprostol, and (3) misoprostol.

Mifepristone is a progesterone antagonist that blocks the effects of progesterone by competing with endogenous progesterone for receptor binding. The primary effect is on the uterus, where it blocks the effect of progesterone on the endometrium and decidua. The endometrium degenerates and is shed, disrupting the implanted embryo/fetus. The endometrial lining and its contents are expelled. The normal suppression of uterine activity induced in the pregnant uterus by progesterone is lost. The cervix is dilated and softened by poorly understood mechanisms.

Methotrexate is a folic acid antagonist that works by inhibiting dihydrofolate reductase, an enzyme needed to make DNA. In its role as an antimetabolite, methotrexate is toxic to the rapidly dividing cells of the trophoblast.

Misoprostol is a prostaglandin analog that acts by causing uterine contractions, which evacuate the uterine contents.

Mifepristone and misoprostol

Medical abortion using mifepristone and misoprostol at up to 49 days' gestation has been approved by the US Food and Drug Administration (FDA). Patients must meet the following criteria:

• Forty-nine days or less from last menstrual period
• No contraindications for an outpatient procedure
• Capability and willingness to follow the procedures and instructions associated with medical abortion
• Willingness to consent to surgical abortion if medical abortion fails
• No contraindications for the medications used for medical abortion

The procedure requires 3 visits, as follows:

• Day 1
• • Counseling is performed, and consent is obtained.
  • History is obtained, and physical examination is performed.
  • Pregnancy is dated by dates, sizing, and ultrasound.
  • Hemoglobin and blood type are checked.
  • Mifepristone 600 mg is given orally. (If the patient vomits 15 min or more after administration, absorption is probably adequate.)
• Day 3
• • RhoGAM is administered if needed.
  • Misoprostol 400 mcg is given orally.
  • Patients are monitored for 4 hours. (Fifty to 75% abort within 4 h of misoprostol administration.)
  • Give Tylenol, Tylenol with codeine, or a nonsteroidal anti-inflammatory drug (NSAID) for pain relief. Avoid aspirin and other medications with anticoagulant properties.
• Day 15
• • Assess completion of abortion by physical examination and ultrasound.
  • Review aftercare measures and contraception.

The following variations on this protocol have been reported in the literature, with low occurrence of adverse effects, good patient acceptance, and comparable effectiveness:

• Use up to 56 days
• Self-administration of misoprostol 800 mcg per vagina on day 3 at home
• Repeated dose of misoprostol on day 7 if needed

Methotrexate and misoprostol

See Mifepristone and misoprostol for patient selection criteria. Patients may be up to 63 days from their last menstrual period. The procedure requires a minimum of 3 visits, as follows:

• Day 1
• • See Mifepristone and misoprostol, day 1.
  • Administer methotrexate 50 mg/m² intramuscularly instead of mifepristone.
• Days 3-5: RhoGAM is administered if needed.
• Days 5-7
• • Misoprostol 800 mcg per vagina is self-administered at home.
  • Alternatively, repeat misoprostol in 24 hours if no vaginal bleeding occurs.
• Day 8: Assess for completion of abortion using ultrasound.
• • If ultrasound reveals an incomplete abortion, repeat misoprostol.
  • If fetal cardiac activity is present, follow up on day 15.
  • If fetal cardiac activity is absent, follow up on day 36.
• Day 15: Assess for completion of abortion using ultrasound.
• • If ultrasound reveals an incomplete abortion, repeat misoprostol.
  • If fetal cardiac activity is present, obtain a surgical abortion.
• Days 29-45: Assess for completion of abortion using ultrasound.
• • If a gestational sac is still observed, obtain a surgical abortion.
  • If fetal cardiac activity is absent, follow up on day 36.

Misoprostol

For medical abortion in the second trimester (17-24 wk), passive dilators (laminaria, Dilateria, Foley balloon) are inserted into the cervix. A 200-mcg misoprostol tablet is placed in the posterior vaginal fornix, followed by gauze sponges. The misoprostol dose is repeated in 12 hours, and the passive dilators and sponges are removed. Higher dose regimens can also be used. One such regimen is to use 400 mcg of misoprostol followed by 800 mcg 6 hours later, and then every 12 hours. Alternatively, 400 mcg every 6 hours can also be used.

Patients are medicated with promethazine, acetaminophen, diphenoxylate, intravenous/ intramuscular analgesics as needed for pain, fever, nausea, and diarrhea. If the fetus does not deliver in 24 hours, add a 20-mg dinoprostone intravaginal suppository every 3 hours until delivery of the fetus occurs. Add intravenous oxytocin 20-30 U/L of Ringer lactate solution to run at 150 mL/h after delivery of the fetus.

All patients should be counseled and consented for dilation and curettage in the event of a retained placenta.

Selective reduction

The techniques available for selective reduction include the following:

• Intracardiac injection (potassium chloride or digoxin)
• Cord occlusion techniques
• • Embolization with alcohol, enbucrilate gel
  • Nd:YAG laser photocoagulation
  • Fetoscope cord ligation
  • Bipolar cord coagulation
  • Monopolar cord coagulation

Medications

Drug Category: Abortifacient agents - Used to produce abortions.

Drug Name - Hypertonic saline, 20% sodium chloride injection (Intra-amniotic injection 20%)- Used in second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents. In instillation techniques, cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories). 

Adult Dose - Inject 40 g (200 mL) transabdominally into amniotic sac 
 
Pediatric Dose - Not established 
 
Contraindications - Increased intra-amniotic pressure, blood disorders (ie, coagulation factor deficiencies, thrombocytopenia, fibrinolytic defects) 
 
Interactions - Terbutaline may antagonize effect on uterine activity; indomethacin may increase time from induction to abortion
 
Pregnancy - C-Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
 
Precautions - Caution in patients with cardiac disease, hypertension, epilepsy, serious renal impairment, or pelvic adhesions 

Drug Name - Hypertonic urea, urea 40-50% injection (Ureaphil)-Used in second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents. In instillation techniques, cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories).

Adult Dose - Inject 80 g (40-50% solution in D5W) transabdominally into amniotic sac
 
Pediatric Dose - Not established 
 
Contraindications - Documented hypersensitivity; severe renal impairment; frank liver disease; intracranial bleeding; sickle cell anemia
 
Interactions - Aspirin may increase time from induction to abortion

Pregnancy - C-Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
 
Precautions - Monitor for fluid and electrolyte imbalances

Drug Name - Dinoprost, PGF2a (Prostin F₂ Alpha)-Not commercially available in the United States. Used in second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents. Use a test dose of 2.5-5 mg followed by 17.5-35 mg. In instillation techniques, cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories).

Adult Dose - Inject 20-40 mg transabdominally into amniotic sac
 
Pediatric Dose - Not established 
 
Contraindications - Documented hypersensitivity; acute pelvic inflammatory disease; wanted pregnancy 

Interactions - Increased effect or toxicity of oxytocic agent

Pregnancy - X-Contraindicated; benefit does not outweigh risk

Precautions - Caution in patients with anemia, asthma, diabetes mellitus, epilepsy, compromised uterus (ie, fibroid tumors, surgery), cardiovascular disease, hypertension or hypotension, renal or hepatic impairment; associated with GI distress, flushing, headache, arrhythmias, angina, uterine rupture, dyspnea, wheezing, blurred vision

Drug Name - Mifepristone, RU-486 (Mifeprex)-Progesterone antagonist. Competes with endogenous progesterone for receptor binding on the endometrium and decidua. Normal suppression of uterine activity induced in the pregnant uterus by progesterone is lost. Endometrium degenerates and is shed, disrupting the implanted embryo/fetus. Endometrial lining and its contents are then expelled. The cervix is dilated and softened by poorly understood mechanisms.

Adult Dose - <49 days since LMP: 600 mg mifepristone PO as single dose, follow in 48 h with 400 mcg misoprostol PO
Alternative: 600 mg mifepristone PO as single dose, follow in 48 h with 800 mcg misoprostol PO; may repeat misoprostol on day 7 prn; regimen may be effective up to 56 d since LMP
 
Pediatric Dose - Not established 
 
Contraindications - Documented hypersensitivity; anticoagulant therapy; bleeding disorders; contraceptive devices (IUDs); ectopic pregnancy; adrenal insufficiency

Interactions - Decreases effect of corticosteroids; increases levels of warfarin, alfentanil, benzodiazepine (ie, alprazolam, triazolam, midazolam); antiretroviral protease inhibitors; calcium channel blockers (ie, nifedipine, diltiazem, verapamil); carbamazepine; cilostazol; cyclosporine; fentanyl; atorvastatin, lovastatin, simvastatin, cerivastatin (removed from US market 8/8/01); quinidine; quinine; sertraline; adverse cardiac effects, cisapride, dofetilide, pimozide

Pregnancy - X-Contraindicated; benefit does not outweigh risk

Precautions - Caution in patients with cardiovascular disease, pulmonary disease (ie, asthma, COPD), diabetes mellitus, renal or hepatic impairment

Drug Name - Methotrexate (Folex PFS, Rheumatrex)-Folic acid antagonist inhibits dihydrofolate reductase, an enzyme needed to make DNA. Antimetabolite property is toxic to the rapidly dividing cells of trophoblast. Methotrexate and misoprostol regimen may be used up to 63 d since LMP.

Adult Dose - 50 mg/m² IM or 50 mg PO, followed by 800 mcg misoprostol PV 5-7 d later, may repeat misoprostol in 24 h if no vaginal bleeding occurs
 
Pediatric Dose - Not established 
 
Contraindications - Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency

Interactions - Oral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response; coadministration with NSAIDs may be fatal; indomethacin and phenylbutazone can increase plasma levels; may decrease phenytoin serum levels; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity; may increase plasma levels of thiopurines

Pregnancy - X-Contraindicated; benefit does not outweigh risk

Precautions - Has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested)

Drug Name - Misoprostol (Cytotec)-Synthetic prostaglandin E₁ analog. Abortifacient effect results from increased frequency of uterine contractions. May be used alone or as part of regimen with mifepristone up to 49 d since LMP or with methotrexate up to 63 d since LMP.

Adult Dose - During second trimester (17-24 wk): 200-mcg tab placed in posterior vaginal fornix, repeat in 12 h; if fetus not delivered in 24 h, add 20-mg dinoprostone intravaginal supp q3h until delivery of fetus
With mifepristone: 400 mcg PO 48 h after mifepristone
With methotrexate: 800 mcg PV 5-7 d after methotrexate, if no vaginal bleeding repeat in 24 h
 
Pediatric Dose - Not established 
 
Contraindications - Documented hypersensitivity

Interactions - None reported

Pregnancy - X-Contraindicated; benefit does not outweigh risk

Precautions - Caution in patients with renal impairment and in elderly patients

Drug Name - Dinoprostone, PGE2 (Prostin E₂ suppository)-Induces uterine contractions by stimulating myometrium. Used during second-trimester medical abortions if fetus does not deliver in 24 h. Also used during instillation technique abortions to make cervix inducible.

Adult Dose - Medical abortion: 20 mg PV q3h until delivery of fetus occurs
 
Pediatric Dose - Not established 
 
Contraindications - Documented hypersensitivity; acute pelvic inflammatory disease; uterine fibroids; cervical stenosis

Interactions - Increased effects of oxytocics

Pregnancy - C-Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions - Caution in patients with anemia, asthma, cervicitis, infected endocervical lesions, acute vaginitis, diabetes mellitus, epilepsy, compromised uteri (ie, fibroid tumors, surgery), cardiovascular disease, hypertension or hypotension, renal or hepatic impairment; associated with GI distress, headache, arrhythmias, angina, uterine rupture, dyspnea, wheezing

Surgical therapy

Surgical abortion techniques available for therapeutic termination of pregnancy include the following:

• Manual vacuum aspiration (ie, menstrual extraction)
• Suction curettage
• Dilation and extraction
• Hysterotomy
• Hysterectomy

The choice of surgical abortion technique depends on the gestational age of the pregnancy; the expertise of the available medical staff; the clinical importance of obtaining an intact fetus; and the medical, surgical, psychiatric, and anesthetic contraindications to the various techniques. See Surgical Management of Abortion for a detailed discussion of surgical abortion techniques.

Preoperative details

For selective reduction procedures, evaluation of the fetuses using chorionic villus sampling or amniocentesis can assist in selection of the appropriate fetuses for reduction.

The use of ultrasound to assess fetal growth, fetal heart rate, and fetal nuchal thickening can also be helpful in the selection process. Criteria such as nuchal translucency of more than 3 mm, a lag in growth longer than 3 days, or a heart rate less than 80 beats per minute can be used to select the appropriate fetus for reduction.

Follow-up

For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Procedures Center. Also, see eMedicine's patient education articles Abortion, Miscarriage, and Dilation and Curettage (D&C).

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

As with all interventions, complications are associated with all methods used for termination of pregnancy. For complications associated with surgical abortion, see Surgical Management of Abortion. Medical abortions in the first trimester are safe and well-tolerated procedures. The major problems are decreased effectiveness of medical abortion with increasing gestational age and the long interval between administration of medication to completion of abortion for certain medications (eg, methotrexate, tamoxifen).

Complications and adverse effects associated with specific medications are as follows:

• Methotrexate and misoprostol: Complications associated with the proper dose are rare, but the following can occur:
  • Stomatitis (0.66%)
  • GI morbidity
    • Nausea (10-37%)
    • Vomiting (7-25%)
    • Diarrhea (2-52%)
  • Thrombocytopenia
  • Chemical hepatitis
  • Failed abortion (4-12%)
• Mifepristone and misoprostol
  • Transfusion (0.1%)
  • Pain requiring narcotic analgesia (4-15%)
  • Vomiting (12-44%)
  • Diarrhea (7-39%)
  • Failed abortion (2-6%)
• Misoprostol and tamoxifen
  • Vomiting (28%)
  • Diarrhea (8%)
  • Failed abortion (8%)
• Misoprostol alone
  • Nausea (24%)
  • Vomiting (25-26%)
  • Diarrhea (58%)
  • Headache (13-15%)
  • Fever (35%)
  • Chills (54-57%)
  • Failed abortion (6-8%)

Complications associated with instillation techniques are as follows:

• Hemorrhage requiring transfusion (0.32-1.72%)
• Infection
• Incomplete abortion
• Cervical laceration
• Hypernatremia and sodium load (saline)
• Muscle necrosis (myometrial injection of saline or urea)
• Adverse GI effects
• Unintended surgery (0.04-0.08 cases per 100 instillations)
• Disseminated intravascular coagulopathy (saline, 658 cases per 100,000 instillations)

Urea instillation abortions are reported to be safer than saline abortions. Prostaglandin-induced second-trimester abortions are safer than saline abortions and have a lower induction-to-completion time.

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. Intermediate risk of mortality occurs with instillation procedures. The highest mortality rates for second-trimester abortions are associated with major surgical procedures (ie, hysterotomy, hysterectomy).

Selective reduction procedures are not included in the statistics for second-trimester abortions. For the rare condition of monochorionic twins, selective reduction cord occlusion techniques are reported by Challis et al to have premature rupture of membranes in up to 30% of cases. The more common method of intracardiac injection techniques for selective reduction is associated with premature rupture of membranes in 13% of triplet pregnancies reduced to twins and in 19.3% of quadruplets reduced to twins. The risk of miscarriage in a pregnancy undergoing selective reduction is inversely proportional to the number of fetuses in the initial pregnancy (ie, quintuplet, 24.8%; triplet, 8.3%)

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Advantages of medical abortion are as follows:

• Can be performed without delay
• Avoids anesthesia and surgical risks
• Psychological advantage - Patient control
• Wider availability of abortion services
• Increased patient choice

Advantages of surgical abortion are as follows:

• More effective than medical abortion
• Shorter completion time
• Shorter bleeding duration
• No exposure to potential teratogens
• Can be performed later in gestational age
• Fewer visits

Surgical abortion is 99% effective in terminating pregnancy. Medical abortion using mifepristone and misoprostol has a mean effectiveness of 94%. Medical abortion using methotrexate and misoprostol has effectiveness ranging from 88-96%. Medical abortion in the second trimester using misoprostol has effectiveness ranging from 40-89% within 24 hours. Instillation methods of abortion have effectiveness ranging from 81-86% at 48 hours to 97% at 72 hours.

As with all interventions, complications are associated with all the methods of termination of pregnancy. For complications associated with surgical abortion techniques, see Surgical Management of Abortion.

Medical abortions in the first trimester are very safe and well-tolerated procedures. The major problem is decreased efficacy with increasing gestational age. In the case of methotrexate, a long period of time between administration of medication to abortion is problematic.

First-trimester abortions performed by surgical or medical methods are well tolerated, have little effect on future fertility, and are not associated with long-term psychological consequences. Second-trimester abortions are well known to be associated with increased risk of morbidity and mortality with increasing gestational age. An association of increased risk for preterm delivery after dilation with metal dilators has been reported.

FUTURE AND CONTROVERSIES

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Future research is expected to evaluate alternative protocols for medical abortion.

The potential exists for wider use of medical management of incomplete and missed abortions as the techniques for medical abortion become commonplace.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

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Article Last Updated: Jun 2, 2006