Background: In the
United States and worldwide, elective termination of pregnancy remains
common. Accurate statistics have been kept since the enactment of the 1973
Supreme Court decisions legalizing abortions. Since then, approximately
1.3-1.4 million abortions have been performed annually in the United
States, and worldwide some 20-30 million legal abortions are performed
annually, with another 10-20 million abortions performed illegally . 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 available on demand.
In spite of the introduction of newer, more effective, and more widely
available contraceptive methods, more than one 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 one half end in elective terminations. Abortion is still one
of the most common medical procedures performed in the United States each
year, and more than 40% of all women will have a pregnancy terminated by
abortion at some time in their reproductive lives. Each year in the United
States, almost 3% of all women of reproductive age terminate their
pregnancies. While women of every social class seek terminations, the
typical woman who terminates her pregnancy is young, white, unmarried, and
Legalization of abortion
Since the landmark 1973 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: 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, and it
is yet unclear as to how these laws will apply to medical abortions. Since
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; performing a specific abortion would
constitute 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. A pending bill in Maryland
proposed that hospitals provide emergency contraception to all rape
victims who seek treatment. The Maryland legislature, however, adjourned
in April 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, there is a trend 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 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 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 herself.
The first federal law on the subject was the notorious Comstock Law of
1873 that permitted a special agent of the postal service to open mail
dealing with abortion or contraception in order 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
In 1965, there were 265 deaths due to illegal abortions. Twenty percent
of all pregnancy-related complications in New York and California were due
to abortions. A series of 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). The movement lawyers were committed to universal
access to rights at a time when states were gradually 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 Supreme Court in a decision that instantly granted the
right of a woman to seek an abortion.
In 1973, in an opinion written by the Nixon Supreme Court appointee
Harry Blackmun, 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 their medical decisions in the first
trimester of pregnancy.
Blackmun, writing for the majority, sidestepped the question of
viability, 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 use of federal
funds for abortions, except in the case of maternal life endangerment.
Since then, it is estimated that up to a third of public funding
recipients cannot obtain an abortion because of lack of funds.
Loosely defined, the term viability is the fetus’ ability to survive
extrauterine life with or without life support. A number of landmark
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, no reliable or medically acceptable tests exist for
this prior to 28 weeks.
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 because of its inclusion of mandatory
waiting periods, elaborate consent processes, and record-keeping
regulations, Planned Parenthood v Casey tried to account for the
variability of viability by inserting language recognizing that some
fetuses never attain viability (eg, anencephalics). 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 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 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 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, the Kentucky Senate passed two abortion-related bills.
SB 151 makes the existing consent laws more rigorous by requiring a woman
to meet with a provider in person to receive pre-abortion counseling.
Sociologic research shows that most minors do involve their parents in
their decision to abort (45%). However, these laws have fostered a new
ominous trend: minors obtaining abortions significantly later in their
pregnancies and often traveling great distances to states with no such
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 states, laws have banned these procedures; in only eight states
are these laws enforced. In his first administration, President Clinton
vetoed 2 bills banning such abortions. The 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 Supreme Court’s
decision was that the Nebraska law did not contain an exception to protect
the health of the mother, and the law also was thought to “unduly burden”
a woman’s choice to end her own pregnancy.
Recently, the Department of Justice filed an amicus brief, on behalf of
the Bush administration, asking the Sixth United States 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 Supreme Court struck down
Nebraska’s ban on late term abortions for the same reason—because it may
be necessary if a woman’s life is in danger. However, the Department of
Justice states the Ohio ban is constitutional because it includes the
provisions set up by the Supreme Court in Stenberg.
Providers of elective induced abortions are generally obstetricians and
gynecologists. However, many studies have illustrated the safety of
allowing a variety of practitioners of various disciplines, both physician
and nursing, 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. There has been a “graying” of
providers who continue to perform abortions. Most represent an older
population of clinicians who became committed in providing access to safe,
legal abortions after caring for young women who suffered or died from
complications of an illegal abortion. For example, the number of abortion
providers decreased by 14% between 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.
New York City Mayor Michael Bloomberg (R) proposed a policy that will
include abortion training for medical residents in all 11 of the city’s
hospitals. Recently, there has been a decline in the number of abortion
providers in the United States 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
Medical abortion protocols have the potential to expand the number of
available providers, as it is only necessary to arrange for backup with a
provider who can perform a surgical abortion and it is unnecessary to have
a staff willing to assist at a surgical abortion. The role of nurse
practitioners, with valid prescription privileges, is unclear at the
present time, but these providers may aid in expanding abortion access as
The development of more advanced surgical techniques has allowed for
safe second trimester terminations and, statistically, more of these have
been performed. The Food and Drug Administration (FDA) recently has given
approval to Mifeprex (mifepristone, 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 reviewed in this chapter as well (see Medical/Legal
Abortion postoperative care often is provided at sites that did not
perform the termination of pregnancy, and strategies for follow-up care
for women whose pregnancies have been terminated are important for all
providers of primary care for women.
The development of accurate over-the-counter (OTC) 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 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 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 about 2-4% of failed abortions
requiring surgical abortion and about 5-10% of incomplete abortions,
depending upon the stage of gestation and the medical products used. For a
review of multiple studies see Kahn et al 2000. Patients who select a
medical abortion express a slightly greater satisfaction with their route
of abortion and, in the majority of cases, express a wish to choose this
method again should they have another abortion. Research needs to be done
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 to provide surgical abortions
exists, in a recent study by Koenig et al providers who do not perform
surgical abortions have indicated a willingness to provide medical
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.
The 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 approved drugs for other indications that can be used for
medical termination of pregnancy. Additional research will determine
exactly which regimen is the best 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
- In the US: Abortion statistics are available from a
variety of sources, including, the CDC, the Alan Guttmacher Institute, and the National Abortion
Federation. Information and specific instructions regarding state
requirements for abortion reporting are available from vital statistics
offices in each state health department. Comprehensive statistical
information is regarded as important in ensuring the utmost in patient
safety (Centers for Disease Control and Prevention).
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 (see Centers for Disease Control and Prevention). 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, see Centers for Disease Control and Prevention.
- Internationally: 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 some 20 million of these performed unsafely because of
conditions or lack of provider training. Maternal mortality is 600,000
per year due to pregnancy-related causes, and 99% of these deaths are in
Mortality/Morbidity: The safety of abortion is well
established, with infection rates less than 1%, and less than 1 per
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.
Race: In 1996, of the women who obtained legal
abortions, 59.1% were white, 35, 2% were black, and 5.7% were other (of
the other, 16.1% were Hispanic). These data can be seen at http://www.cdc.gov/nccdphp/drh/pdf/48ss4_tbl1.pdf.
History: Most terminations
of pregnancy are performed after a brief and targeted gynecologic and
obstetric history. Providers should obtain information about any prior
pregnancies and information regarding any treatment or care during this
pregnancy. The history taking also should focus on prior gynecologic
disease with particular attention to previous or current sexually
transmitted infections (STIs). Information regarding medical history that
might be important includes a history of diabetes, hypertension or heart
disease, anemia or bleeding disorders, or previous gynecologic surgery. A
history of active medical problems may mean 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 to
pregnancy exist. Perinatologists, obstetricians, and abortion
counselors prefer to put the risks in the context of statistical
likelihood of complications and then let the patient make her final
- 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 (TOF), aortic stenosis, myocardial
infarction history, and presence of artificial heart valves. Greater
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
- Nondirective counseling can help a woman select her
- 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
- Many hypoplastic cardiac conditions also are incompatible with
life. However, with cardiac transplantation, some infants now can
survive birth with these defects.
- Anomalous conditions that are common and encountered in abortion
counseling include most fetal cardiac anomalies, trisomy 21, open and
closed neural tube defects, limb, face, or cleft abnormalities,
esophageal or duodenal atresia, chest and abdominal wall defects,
cystic kidneys or hydronephrosis, intracranial calcifications
suggestive of viral disease, or diaphragmatic defects.
- A brief physical examination usually is 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
- Note any vaginal or cervical discharge, the nature of the cervix,
and any lesions. Document the presence or absence of any ovarian
- If the patient is going to have general anesthesia, a typical
screening preoperative physical can be performed.
Early Pregnancy Loss
Other Problems to be Considered:
Cervical dysplasia or neoplasia
Bleeding or clotting disorders
Benign Lesions Of The Uterine Corpus
- Pregnancy tests are used to confirm the presence of a pregnancy,
and home tests are reliable enough to accept their results in some
- Hemoglobin (Hb) or hematocrit (Hct) levels always are assessed.
Full CBC is optional but may be indicated if abnormalities are
detected with the Hb or Hct test.
- STI screening typically includes a test for gonorrhea culture (GC)
or chlamydial test (CT). Screening for other STIs, such as syphilis or
HIV disease, is usually prohibitively expensive, but patients who are
found to have GC or CT should be offered these tests.
- Rh typing is always performed. ABO typing is optional.
- Use of human chorionic gonadotropin titers
- If an abortion is being performed prior to 5 weeks from LMP,
titers preoperatively can be very useful. Managing most abortion
procedures without an HCG titer is within the standard of
- Vaginal wet preparations, pH testing, or urine dipstick analysis
usually are performed for standard indications.
- If a woman is discovered to have a concomitant infection, it may
need to be treated before she has the abortion.
- First trimester sonography: The content of the examination is what
typically is 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, ultrasonography preoperatively is the standard of
care. Conduct these examinations like other second trimester screening
exams. If anomalies are detected, women should be offered a referral
for targeted examinations that can delineate specific fetal disease
conditions. It is not unusual for women to decline further
investigation if their abortion decision does not hinge on the
Histologic Findings: Pathologic analysis
of tissue typically is 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 suspected
or within a week to 10 days if no pathology is suspected. Many fetal
anomalies can be detected on anatomic inspection of the fetus, but only
intact procedures or induction of labor reliably offer a fetal specimen
that can be evaluated adequately.
- Papanicolaou (Pap) smears are optional specifically prior to
procedure, but patients should be informed of their need for Pap smears
as part of their postabortion contraceptive
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, having histologic analysis reveal the presence of a partial molar
pregnancy or an incomplete molar pregnancy is not uncommon.
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 technical
ability or the protocols established to offer medical abortions.
Therefore, most abortions are performed surgically.
- 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. Now that medical protocols are
becoming more widely available, the risks and benefits of both medical
and surgical abortions should be reviewed.
- The counseling process is aimed primarily at the woman herself, as
well as those she chooses to have involved. Studies indicate that
males are involved in more than 40% of the decisions, but only scant
research has been done on male involvement in the process. Some women
can reach a decision quickly; others take longer to decide. The
counseling process should offer referrals for those who need ongoing
- 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
- 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 the 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
- 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. Laws
directed towards the providers usually also exist. Providers have an
obligation to find out about their local laws and to comply with
- First and second trimester medical abortion
- First trimester terminations are accomplished medically with
misoprostol alone, methotrexate-misoprostol combination regimens, or
Mifeprex (RU-486) with or without misoprostol. Other prostaglandins
are in use in other countries.
- Medical abortions are indicated for women who consent to a medical
abortion but also are willing to undergo a surgical abortion if the
medical abortion fails. Gestational age usually is less than 42-49
days, but many protocols including up to 63 days from LMP are in the
literature. Literature has also documented safety of medical abortion
protocols between 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
- Contraindications to medical abortion vary depending upon 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
- The Mifeprex/misoprostol appointment schedule is as follows: On
day 1, Mifeprex 600 mg PO is administered in the office. On day 3,
misoprostol 400 mcg PO or vaginally is administered at home and with 4
hours of observation. Between days 12 and 20, the patient returns to
the office to determine if the abortion has been completed. If it has
not, repeat misoprostol is administered or the patient may undergo a
- The methotrexate/misoprostol regimen is similar. 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
- 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.
- In a recent comparison study by Perry of intra-amniotic
15-methyl-prostagalin 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.
- 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: 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 above 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 requires progress, more laminaria are
inserted and left for longer amounts of time. 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.
Prior to insertion, Betadine preparation of the cervix is
performed. 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 cc of
lidocaine administered paracervically can provide comfort. The patient
must understand that laminaria insertion is the beginning of the
abortion procedure. Pregnancies have safely been 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: Failure to dilate the cervix is not common, but
if no dilators (the smallest is a 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 a medical
abortion. Waiting until the patient is further in pregnancy is an
option, as is dilating while watching with sonographic
- Intraoperative care of patients undergoing surgical abortion
- Most patients having an early termination of pregnancy can have
their abortion performed under "vocal sedation" (talking the patient
through the procedure) as well as local sedation. Most patients do not
need an intravenous access for medication.
- If heavy sedation is selected, then intravenous fluids with
lactated Ringer solution or one half normal saline are suitable, at
rates appropriate for the patient's age and weight.
- If a patient is administered 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.
- 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
- 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 lidocaine 1-2% or
Nesacaine 1%. No epinephrine is necessary. The local anesthetic takes
effect rapidly, and studies of the exact route of administration
(several spots around the cervix or at 3 and 9 o'clock) 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, 5-9 mm cannulas are used. The suction
cannulas can be soft or rigid, straight or bent, and experienced
providers can use either type interchangeably. Both suction syringes
and the 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 cc for very early terminations, or as heavy as 100-250
cc. Amounts over 200 cc blood loss usually are 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 supplemented for pain relief. Others
have had success with sublingual diazepam, and intramuscular Toradol
(ketorolac tromethamine) can be used.
- Abortions in the late 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 (5-10 cc range for very
early abortion and 50-100 cc range for later procedures).
- Tissue inspection for completeness is an essential part of the
- Dilatation and curettage
- This specifically is a term that usually is applied to a
diagnostic gynecological procedure or the treatment of an incomplete
- The procedure usually is accomplished with similar dilatation
procedures, but the 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 similar preoperative preparation to
first trimester preparation; however, the dilatation must be
accomplished over hours and, in some cases, days. See Preoperative
care of patients undergoing surgical abortion.
- The procedure requires the cervix to be dilated to 2-3 cm,
admitting at least a #16 Hegar dilator or a size 53 French (Fr)
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 use of the forceps that
are 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 in
the range of 100-350 cc.
- 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.
- Very few providers perform the procedure. It usually is 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 also has been referred to as intact dilatation and
extraction and has been called "partial birth abortion" by abortion
- Induction of labor
- Most physicians have experience with the standard Pitocin
protocols for labor induction, and these can be used in the case of a
second trimester of pregnancy.
- Premature rupture of membranes is one indication for this method.
- Research generally indicates better success with prostaglandin
methods, and this method typically is not employed.
- Hysterotomy is reserved for very few cases. 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 extra uterine 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: The counseling process should offer
referrals for those who need ongoing support.
Diet: Patients may eat a regular diet.
- Tampons, douche, and intercourse should be avoided for one
- Heavy activity or lifting should be avoided for a few
The procedure usually is performed under
local anesthesia. For those modestly tolerant of pain, either intravenous
sedation or administration of a preoperative antianxiolytic agent can be
used. Narcotics can be used for pain control but usually are not
necessary. A variety of agents may be useful for contracting the uterus
postprocedure, although in a typical first trimester procedure, none are
necessary. Agents useful to control bleeding include Pitocin, Methergine,
or prostaglandins. Mechanical devices to control hemorrhage can be useful
as well, which typically consists of intrauterine insertion of a Foley
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
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 as
well as all the anesthetic that is necessary for early abortion
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
||Lidocaine (Xylocaine) -- Used for
paracervical block during procedure to keep patient comfortable.
Local anesthetic blocks nerve impulses by decreasing sodium influx
across neuronal cell membranes. Alternatively, chloroprocaine
(Nesacaine) may be used.
||Popular mixture used (12-20 mL in
divided doses to be injected in each patient): |
(1) 50 mL vial of
1% or 0.5% lidocaine and draw off 5 mL (2) add 2-4 U (0.1 mL) of
vasopressin (3) add 5 mL of buffer (8.4% sodium bicarbonate)
Atropine is added, dose is 2 mg/50 mL
Deep injections are more
efficacious than superficial, inject 10-15 mL halfway between the os
and the periphery of the cervix at 4 sites (12, 3, 6, 9 o'clock) at
a depth of 0.75-1 inch
Adams-Stokes or Wolf-Parkinson-White syndrome; SA, AV, or
intraventricular heart if artificial pacemaker is not in place
||Increased toxicity with cimetidine,
beta-blockers; additive cardiodepressant action with procainamide,
tocainide; increases effects of succinylcholine
||B - Usually safe but benefits must
outweigh the risks.
||Associated with malignant
hyperthermia; increased risk of CNS and cardiac adverse effects in
the elderly; seizures, heart block, and AV conduction abnormalities
have occurred; caution with heart failure, hepatic disease, hypoxia,
hypovolemia, shock, respiratory depression, and
Category: Antiprogesterones -- Antiprogesterone class of
drugs for medical termination of pregnancy are used. 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.
||Misoprostol (Cytotec) -- Not
approved for use in pregnancy, yet is an invaluable medication
widely used for cervical preparation for abortion, labor induction,
and as a medical abortifacient. Provides safe, passive method of
cervical dilatation and should be considered for preabortion
ripening when prior uterine surgery (ie, LEEP, C-section) are known
risk factors for uterine perforation during surgical abortion. Can
be administered orally or vaginally. Some studies show premoistening
tablets placed vaginally helps absorption. Patients can be
instructed in self-administration to help time the dose in synchrony
with their abortion procedure.|
In a study by Singh of
primigravid women (6-11 wk gestation), 93.3% achieved dilatation of
the cervix of 8 mm or greater after 3 h postintravaginal misoprostol
400 mcg, whereas only 16.7% of women achieved this after 2 h of 600
mcg. The 600-mcg group had slightly greater adverse effects (eg,
bleeding, abdominal pain, fever >38ºC). Dosage intended for
cervical ripening can induce abortion in some patients. Oral doses
of 100-400 mcg can be combined with vaginal insertion of
prostaglandins to enhance cervical dilatation.
||Cervical ripening: 25-100 mcg
(vaginally) for term pregnancies, lower doses may need to be
Termination: 200-800 mcg, most patients do not
need repeat dosing for 24 h
pregnancy not intended for termination; glaucoma; sickle cell
anemia; hypotension; mitral stenosis
||Antacids containing magnesium may
||X - Contraindicated in pregnancy
||Inform patient of potential adverse
effects (eg, GI distress, cramping, bleeding); GI distress slightly
greater with oral administration.|
Antimetabolites -- The antimetabolite, methotrexate, has
been used for over 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. This class of
drug to be used for the medical termination of pregnancy, although for
complete expulsion, it usually has to be administered in conjunction with
||Mifeprex (RU-486) -- Progesterone
receptor antagonist, which has 5 times greater affinity for the
receptor than progesterone. By blocking progesterone, the hormone
that maintains pregnancy, abortion can be completed. Cervix is
softened and dilated; decidual necrosis and detachment of the
pregnancy at the endometrium and uterine contractions ensue.
||600 mg PO day 1 of medical abortion
regimen; doses as low as 200 mg reported as efficacious
confirmed/suspected ectopic pregnancy; undiagnosed adnexal mass; IUD
in place; chronic adrenal failure; concurrent long-term
corticosteroid therapy; hemorrhagic disorders; concurrent
anticoagulation therapy; inherited porphyrias
||Not studied yet; possibly
ketoconazole, itraconazole, erythromycin, grapefruit juice;
rifampin, dexamethasone, St John's Wort, some anticonvulsants
||X - Contraindicated in pregnancy
||Abdominal pain, uterine cramping,
nausea, vomiting, diarrhea|
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 typically are used to enhance this
process or to halt immediate postabortion bleeding. In some cases, these
drugs can be potent enough inducers of uterine activity to lead to
abortion without other drugs or regimens.
||Methotrexate (Folex PFS,
Rheumatrex) -- Antimetabolite that works by blocking enzyme
dihydrofolate reductase, thereby inhibiting folate production and,
thus, DNA synthesis. Primarily affects rapidly dividing cells first,
such as trophoblast cells.
||50 mg/m2 IM;
alternatively, 50 mg PO
alcoholism; hepatic insufficiency; kidney disease; inflammatory
bowel disease; clotting disorder; documented immunodeficiency
syndromes; preexisting blood dyscrasias; bone marrow hypoplasia;
leukopenia, thrombocytopenia; significant anemia (Hct<30%)
||Oral aminoglycosides may decrease
absorption and blood levels of concurrent oral methotrexate (MTX);
charcoal lowers MTX levels; coadministration with etretinate may
increase hepatotoxicity of MTX; folic acid or its derivatives
contained in some vitamins may decrease response to
Probenecid, NSAIDs, salicylates, procarbazine, and
sulfonamides, including TMP-SMZ, can increase MTX plasma levels; may
decrease phenytoin plasma levels; may increase plasma levels of
||D - Unsafe in pregnancy
||Nausea, vomiting, diarrhea, hot
flushes, headache, cramping, dizziness; toxic adverse effects on the
hematologic, renal, GI, pulmonary, and neurological
Drug Category: Ergot
Alkaloids -- Also in the category of uterotonics and almost
exclusively used for treatment of postabortal bleeding, atony, or
||Oxytocin (Pitocin) -- Produces
rhythmic uterine contractions and can stimulate the gravid uterus as
well as vasopressive and antidiuretic effects. Can also control
postpartum bleeding or hemorrhage.|
When used as in labor
protocols, can induce second trimester abortion.
||10 U IM after
Alternatively, 10-40 U IV in 1000 mL of IV fluid at
rate high enough to control uterine atony
||>12 years: Administer as in
cardiac arrhythmias with tachycardia
||Pressor effect of sympathomimetics
may increase when used concomitantly with oxytocic drugs, causing
||X - Contraindicated in pregnancy
||Overstimulated uterus can be
hazardous; hypertonic contractions can occur in a patient whose
uterus is hypersensitive to oxytocin, regardless of whether it was
administered appropriately; oxytocin has intrinsic antidiuretic
effect that, when administered by continuous infusion and patient is
receiving fluids by mouth, can cause water
||Methylergonovine (Methergine) --
Acts directly on uterine smooth muscle, causing a sustained tetanic
uterotonic effect that reduces uterine bleeding and shortens third
stage of labor. Administer IM during puerperium, delivery of
placenta, or after delivering anterior shoulder. Also may be
administered IV, over no less than 60 sec, but should not be
administered routinely because it may provoke hypertension or a
cerebrovascular accident. Monitor BP closely when administering IV.
||0.2 mg PO tid/qid for 2-7
Alternatively, 0.2 mg IM/IV repeat q2-4h prn
||<12 years: Not
>12 years: Administer as in adults
glaucoma; Tourette syndrome; anxiety; hypertension
||Concurrent administration of
methylergonovine with vasoconstrictors or other ergot alkaloids may
produce additive effect
||C - Safety for use during pregnancy
has not been established.
||Caution in sepsis, obliterative
vascular disease, or hepatic or renal insufficiency|
Sedatives -- During surgical abortion, relaxation
techniques and local anesthetic is typically all that is required to
adequate pain relief. In some patients, the use of intravenous, oral, or
sublingual sedatives can enhance this effect.
||Carboprost tromethamine (Hemabate)
-- Prostaglandin similar to F2-alpha (dinoprost) but has longer
duration and produces myometrial contractions that induce hemostasis
at placentation site, which reduces postpartum bleeding.
||250 mcg IM; repeat at 15-90 min
intervals to maximum dose of 2 mg
||Documented hypersensitivity; pelvic
||Increases toxicity of oxytocic
||X - Contraindicated in pregnancy
||Caution in cardiovascular disease,
asthma, hypotension or hypertension, adrenal disease, diabetes,
renal or hepatic disease, a compromised uteri, or jaundice; do not
inject IV (may induce hypertension and
Antiemetics -- Antiemetics are not typically necessary
unless patients already have pre-existing nausea and vomiting of pregnancy
or have nausea and vomiting in reaction to general anesthesia.
||Midazolam (Versed) --
Shorter-acting benzodiazepine sedative-hypnotic useful in patients
requiring acute and/or short-term sedation. Also useful for its
||0.5-2 mg IV over 2 min; repeat
q2-3min prn; total IV dose generally 2.5-5 mg
||>12 years: 0.5 mg IV over 2 min;
repeat q3-4min prn
preexisting hypotension; narrow-angle glaucoma; sensitivity to
propylene glycol (diluent)
||Sedative effects of midazolam may
be antagonized by theophyllines; narcotics and erythromycin may
accentuate sedative effects of midazolam due to decreased clearance
||D - Unsafe in pregnancy
||Caution in congestive heart
failure, pulmonary disease, renal impairment, and hepatic failure;
Romazicon is a benzodiazepine antagonist used to reverse the effects
of versed (0.2-0.3 mg IV, may wear off faster than the versed
||Prochlorperazine (Compazine) -- May
relieve nausea and vomiting by blocking postsynaptic mesolimbic
dopamine receptors through anticholinergic effects and depressing
reticular activating system.
||5-10 mg PO/IM tid/qid; not to
exceed 40 mg/d|
2.5-10 mg IV q3-4h prn; not to exceed 10
mg/dose or 40 mg/d
25 mg PR bid
||2.5 mg PO/PR q8h or 5 mg q12h prn;
not to exceed 15 mg/d|
IV dosing is not recommended for
0.1-0.15 mg/kg/dose IM and change to PO as soon as
||Documented hypersensitivity; bone
marrow suppression; narrow-angle glaucoma; severe liver or cardiac
||Coadministration with other CNS
depressants or anticonvulsants may cause additive effects; with
epinephrine, may cause hypotension
||C - Safety for use during pregnancy
has not been established.
||Drug-induced Parkinson syndrome or
pseudoparkinsonism occurs quite frequently; akathisia is most common
extrapyramidal reaction in elderly; lowers seizure threshold;
caution with history of seizures|
Category: Antibiotics -- Most antibiotics are used
prophylactically to prevent postoperative endometritis. Some institutions
have used dosages that would cover CT and GC because patients are often
unavailable for contact after an abortion (lack of providers means many
travel very far to receive their abortion).
||Promethazine (Phenergan) --
Antidopaminergic agent effective in treating emesis. Blocks
postsynaptic mesolimbic dopaminergic receptors in brain and reduces
stimuli to brainstem reticular system.
||12.5-25 mg PO/IV/IM/PR q4h prn
||0.25-1.0 mg/kg PO/IV/IM/PR 4-6
||May have additive effects when used
concurrently with other CNS depressants or anticonvulsants;
coadministration with epinephrine may cause hypotension
||C - Safety for use during pregnancy
has not been established.
||Caution in cardiovascular disease,
impaired liver function, seizures, sleep apnea, and asthma; avoid
accidental intra-arterial injections|
||Doxycycline (Vibramycin) --
Inhibits protein synthesis and thus bacterial growth by binding to
30S and possibly 50S ribosomal subunits of susceptible bacteria.
Prophylaxis of postabortion infections. If contraindicated, use
erythromycin or ampicillin. Suspected cervicitis for chlamydia.
||New ACOG recommendations recommend
100 mg PO 1 h prior to abortion, then 200 mg PO postabortion; this
regimen may produce nausea and vomiting|
100 mg PO bid for 1-3
||2-5 mg/kg/d in 1-2 divided doses;
not to exceed 200 mg/d, not generally applicable
||Documented hypersensitivity; severe
||Bioavailability decreases with
antacids containing aluminum, calcium, magnesium, iron, or bismuth
subsalicylate; tetracyclines can increase hypoprothrombinemic
effects of anticoagulants; tetracyclines can decrease effects of
oral contraceptives, causing breakthrough bleeding and increased
risk of pregnancy
||D - Unsafe in pregnancy
||Photosensitivity may occur with
prolonged exposure to sunlight or tanning equipment; reduce dose in
renal impairment; consider drug serum level determinations in
prolonged therapy; tetracycline use during tooth development (last
one-half of pregnancy through age 8 y) can cause permanent
discoloration of teeth; Fanconilike syndrome may occur with outdated
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.
||Erythromycin (E-Mycin, Ery-tab,
Eryc, Erythrocin) -- Inhibits bacterial growth, possibly by blocking
dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent
protein synthesis to arrest. For treatment of staphylococcal and
streptococcal infections. Prophylaxis of postabortion infections.
Use if doxycycline is contraindicated.
||333 mg PO tid for 3-7 d;
alternatively 500 mg PO bid for 3-7 d
||30-50 mg/kg/d (15-25 mg/lb/d) PO
hepatic impairment; concomitant use of astemizole, cisapride,
||Coadministration may increase
toxicity of theophylline, digoxin, carbamazepine, and cyclosporine;
may potentiate anticoagulant effects of warfarin; coadministration
with lovastatin and simvastatin, increases risk of rhabdomyolysis
||B - Usually safe but benefits must
outweigh the risks.
||Caution in liver disease; estolate
formulation may cause cholestatic jaundice; GI adverse effects are
common (administer doses pc); discontinue use if nausea, vomiting,
malaise, abdominal colic, or fever occur; pseudomembranous
||Rh0(D) immune globulin
(RhoGAM) -- Given to Rh(-) mothers to avoid sensitization to Rh(+)
||<12 wk gestation: 50 mcg (minidose)|
>12 wk gestation: 300 mcg
up to 72 h postabortion
||Adolescent: Administer as in adults
||C - Safety for use during pregnancy
has not been established.
||Anaphylactic shock; fever; do not
administer live virus vaccine within 3 mo|
||Metronidazole (Flagyl) --
Recommended as an alternative for endometritis prophylaxis.
||500 mg tid for 7d postabortion when
allergic to doxycycline; stat when treating suspected bacterial
vaginosis prior to abortion.
||May increase toxicity of
anticoagulants, lithium, and phenytoin; cimetidine may increase
toxicity of metronidazole; disulfiram reaction may occur with orally
||B - Usually safe but benefits must
outweigh the risks.
||Adjust dose in hepatic disease;
monitor for seizures and development of peripheral
Further Inpatient Care:
- Termination of pregnancy never requires inpatient treatment. If the
patient has a medical condition that requires hospitalization, then that
condition's indications for hospitalization should be followed.
- Patients that must have their termination performed by hysterotomy
or hysterectomy are hospitalized according to the needs of their
- Patients with a medical complication of pregnancy termination, such
as a perforation, are cared for according to the treatment
- For the patient who has a fundal perforation, with an instrument
that is not connected to suction, patient observation may be indicated
but usually is not necessary.
- Patients with perforations suspicious of bowel injury may need
exploratory surgery via laparoscopy (if the physician is an extremely
experienced laparoscopist) or an exploratory laparotomy. If these
procedures are used, hospitalization may be required for 1-3 days to
manage the usual postoperative course.
- Antibiotic prophylaxis is recommended for any additional surgery
with broad-spectrum antibiotic coverage administered over at least 24
Further Outpatient Care:
- Postoperative care of a patient after surgical abortion
- Observe patients for a half an hour, checking for abdominal pain,
unusual bleeding, and observing vital signs.
- Anti-D immunoglobulin should be administered on the day of the
procedure to patients who are Rh-negative.
- Patients selecting immediate intrauterine device (IUD) insertion,
depot-medroxyprogesterone acetate (DMPA), or Norplant may begin their
contraceptive this day as well.
- Postoperative appointments are usually 1-3 weeks after the
procedure and are important to ensure timely involution, confirm the
pregnancy termination has been completed, evaluate the patient for
medical complications, offer continuing contraceptive care, and
evaluate psychological status.
- Postoperatively, patients should be given instructions to contact
their providers if they have severe pain, run a fever of 100.4ºF or
higher, or soak through more than 4-5 pads per hour or more than 12
pads in 24 hours. The first 24 hours, a nonaspirin analgesic, such as
acetaminophen, is recommended, and after that time, patients can
switch to a nonsteroidal anti-inflammatory drug (NSAID), such as
ibuprofen or naproxen.
- Provide patients with emergency contact numbers and instructions
regarding where to present if they have an emergency and cannot reach
- Patients may bleed very little, if at all, if they were very early
in gestation, but the most common bleeding pattern is to have bleeding
the day of the procedure, then not much until the fifth postoperative
day when heavier cramping and clotting occurs.
- Patients should not use tampons for 5 days and should not have
intercourse until bleeding has stopped for a week or they have been
cleared by their provider at their postoperative visit.
- With antibiotic use as prophylaxis, postabortion infection rates
in most population groups should be less than 1-2%. Antibiotic use for
the procedure usually is limited to the day of the procedure or a 2-3
day course. The antibiotics used are typically broad spectrum, and
most centers use doxycycline 100 mg bid, with erythromycin for those
who are allergic. If bacterial vaginosis is discovered, then the use
of Flagyl 500 mg bid or Cleocin 300 mg bid PO is selected. Some
providers with caseloads of patients who come from far distances and
are difficult to locate postoperatively may select to administer
longer antibiotic courses to cover the event of a positive CT or GC
test coming back after the patient has left the facility and either
cannot be or does not want to be contacted.
- Most oral contraceptive pills can be started the day of the
procedure or the following Sunday. IUDs can be inserted that day or
with the next menstrual period. DMPA shots can be given that day or up
to 5 days later.
- Patients who have had their pregnancies terminated need a
postoperative evaluation in 1-3 weeks. Women should be offered a contact
number for any questions, and episodes of unusual pain or bleeding
should be cause for an early postoperative visit.
- Uterine perforation: If the patient had a fundal perforation with no
suction applied, then observation for a few hours and evaluation of
hemoglobin levels is standard of care.
- Evaluation of acute abdominal pain postabortion: Suspect acute
hematometra, retained products of conception, pelvic infection, or
perforation with or without bowel involvement.
In/Out Patient Meds:
- Long-term steroid contraception
- Effective contraception is the only reasonable strategy toward
abortion prevention. Since the introduction of the long-acting steroid
contraceptives, abortion rates in the United States have steadily
- Uterine hemorrhage
- Hemorrhage has been defined in a variety of ways; the need for
transfusion is exceedingly rare. If uterine hemorrhage rates include
hemorrhage immediately postabortion, uterine atony rates of hemorrhage
are as low as 5%. Initial hemorrhage should be evaluated by ensuring
complete uterine evacuation.
- The next steps are typically medical: the use of intramuscular
Methergine 0.2 mg, the use of intravenous Pitocin drips with 10-20
mIU/L running at 100-200 cc. Hemabate also is helpful.
- In the past, uterine packing has been used, but this can be
accomplished effectively with the intrauterine inflation of a Foley
balloon. Five cc balloons can be inflated with 30 cc, or 30 cc
balloons can be inflated with up to almost 100 cc of sterile saline.
The inflation should correlate with uterine size.
- Uterine artery embolization can be used if placenta accreta is
encountered, but very few of these procedures have been performed, and
statistical success rates are impossible to evaluate.
- Uterine perforation
- Perforation rates have been estimated to occur in 1 per 250 cases.
They usually are fundal and recognized by the provider at the time of
the procedure. In a study by Pridmore of 13,907 women who underwent
outpatient termination of pregnancy, the perforation rate was 0.05%,
and in the second trimester, procedures from 13-20 weeks, the
perforation rate was 0.32%.
- Risk factors for perforation are previous terminations of
pregnancy, lower segment cesarean sections, and loop electrosurgical
excision procedures (LEEPs) of the cervix. The common denominator is
thought to be scarring of the internal cervical os.
- Fundal perforations only require observation. If the extent of the
perforation cannot be determined, if the patient is medically
unstable, if the suction was applied at the time of the perforation,
or if bowel or fat content was obtained by forceps at the time of a
perforation, surgical evaluation of the patient is necessary. The
surgical evaluation may be performed by an experienced laparoscopist
or by laparotomy.
- Retained products of conception
- Evaluation of the obtained products of conception at the time of
abortion and postabortion uterine scanning have reduced the retained
products of conception rate to less than 1% of cases, and in one
series reported by Hakim, Tovell, and Burnhill of 170,000 cases, only
0.5% incidence occurred in the first trimester. In cases of second
trimester abortions, retained tissue rates are even lower with rates
of 0.2% according to Peterson and 0.5% according to Kafrissen et al.
- Cases of delayed bleeding even after a normal cycle have been
reported. Dilatation and curettage or hysteroscopy are necessary if
bleeding is brisker or if the amount of tissue is determined by
sonography to warrant more extensive procedures. Endometrial color
flow can be helpful in determining retained tissue.
- Endometritis and pelvic inflammatory disease
- Infections postabortion are rare, occurring in fewer than 1% of
cases. These usually are due to preexisting infections, such as
bacterial vaginosis, cervicitis or salpingitis, or a failure of
- The usual criteria for the diagnosis of pelvic inflammatory
disease (PID) should be used. A thorough discussion of PID and the
criteria for diagnosis can be found at http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00031002.htm.
- Coexistent ectopic pregnancy
- Residual positive HCG titers are not uncommon, and clinicians need
to be vigilant in their evaluation of persistent positive pregnancy
tests in order to avoid missing an ectopic pregnancy.
- Pelvic ultrasonography is the most helpful tool. Presence of
significant tenderness on postoperative exam, a history of continued
pain, and increasing or plateauing HCG titers should make a clinician
suspicious. Coexistent interactive and extrauterine pregnancies are
observed only in extremely rare cases.
- Asherman syndrome
- Postabortion uterine synechiae (or adhesions) that can obliterate
part or all of the endometrial cavity have been reported. This is
thought to be more likely secondary to endometritis than the
instrumentation of the uterus, but sharp curetting after the abortion
procedure should be avoided to avoid denuding the basal layer of the
- The diagnosis is made by hysteroscopy or hysterosalpingogram in a
patient who presents with postabortion amenorrhea.
- Few long-term sequelae of abortions have been documented. Although
a syndrome of posttraumatic stress has been reported, the literature
has not been able to separate the stressors of the patient's social
situation that lead to the abortion from the abortion procedure
- Initial studies seemed to indicate a greater risk of elective
termination than that of term birth. Most of these data have been
refuted. In the Iowa Women's Health Study, women aged 55-64 years had
their health records of the state linked with the national Cancer
Institute's Surveillance, Epidemiology and End Results Program (SEER).
For information on the SEER program. Only 1.8% of the women in this study
reported induced abortion, which is lower than other age groups will
be as they reach that age, but the relative risk of breast cancer for
those with prior induced abortion was 1.1%. These results must be
reevaluated over time.
- One recent article reported a slightly greater incidence of
adenomyosis postabortion. A study by Zhou of 15,727 women who had
induced abortions compared with 46,026 women who did not have induced
abortions showed an increased risk in preterm and postterm pregnancy
after induced abortion. Another study by Hendricks showed that both
induced abortion and prior cesarean section increased the risk of
placenta previa. In women with 3 prior cesarean sections, the relative
risk was 2.4 and the risk of having 2 or more previous abortions was
- In another study by Eras, abortion was suggested as a protective
factor against the development of preeclampsia in a subsequent
pregnancy in women with no prior deliveries.
- Psychologic consequences of abortion
- Generally, the psychological health of the abortion patient
parallels her psychologic health prior to seeking an abortion. If the
woman needed to have the abortion in secrecy, then long-term
psychologic sequelae, such as intrusive thoughts, are more common.
- Many studies actually have demonstrated improved psychological
well-being after abortion. For the studies that have shown this, the
improvement in psychological health is suspected to be more reflective
of the patient dealing with the social issues that led her to select
abortion to begin with.
- Sometimes, confusion over normal emotions, such as sadness and
grief versus psychological illnesses (eg, depression), seems to occur.
The most common feeling experienced after an abortion is that of
relief and confidence in the decision. Few women may experience
feelings of grief and guilt postabortion, and these feelings usually
pass within days to weeks in most cases and do not lead to
psychological sequelae. One study demonstrated that the risk for
serious psychiatric illness postabortion was 1%, whereas with live
birth it was 10%. Few studies on these data exist, partly because
studies performed earlier gave no indication for psychiatric sequelae
so no new findings have been researched. Considering that over 1.5
million abortions are performed in the United States each year, if an
epidemic of psychiatric sequelae due to the procedure occurred, it
would be observed by now.
- Many confounding factors are involved in a women's emotional
status during the time of her abortion. Relationships, religion, age,
social support, and previous psychological stability all play a part.
- An entire new set of circumstances and feelings exist in cases of
rape and incest. These are often psychologically complex situations
and unique to each case.
- Providers can help women through abortions by presenting options
and explaining the procedures. Counseling with a trained professional
occurs before the abortion. This is a good time to identify factors
that might lead to a patient having difficult feelings after the
abortion. Some factors are low self-esteem, preexisting or past
psychological illness, lack of emotional support, and past childhood
sexual abuse. The counselor can then confront these issues before the
procedure and help the patient assess specific needs and improve
- Fertility is not impaired. Prognosis is excellent.
- Give patients information about abortion and how to care for
- Educate patients about birth control options, and discuss when to
start birth control postabortion.
- Abortion rights in the United States
The Status of Major Abortion-Related Laws And Policies in
the States, February 28, 2001.
- The abortion ethical debate has kept termination of pregnancy in
the courts and media since the landmark Roe versus Wade decision. The
original ruling was fairly straightforward, legally confirming a
woman’s right to a private medical decision in selecting a medical
- As the debate has raged and the medical issues have become more
complex, the rulings in the courts and in the legislatures have
extended beyond this simplistic question to restrictions on
gestational age, viability determinations, spousal and parental
consents, enforced waiting periods, enforced language in consents,
enforcement of what provider qualifications must be, the right to use
fetal tissue for research or medical treatments, the rights of
providers and patients to be shielded from overt protest, and,
finally, on access to contraception.
- In a typical year, hundreds of laws and rulings are proposed, some
even specifically criminalize performing abortions. Some laws are
passed, yet they are not enforceable because they are enjoined by a
court order. Current laws are difficult to follow, but a summary from
the Alan Guttmacher Institute can be found at
- Prior to the 1960s, an estimated 9 out of 10 out-of-wedlock
pregnancies were electively aborted. These procedures were performed
in a variety of medical and lay settings, and almost 20% of all
pregnancy-related complications were due to illegal abortions.
- Individuals who perform terminations of pregnancies are bound by
their state's reporting laws. For a complete listing of current
reporting requirements, see http://www.cdc.gov/nchs/data/itop97.pdf
- Roe versus Wade
- An important early decision by the Supreme Court constitutionally
establishing a woman’s right to privacy was Griswold versus
Connecticut in 1965.
- In the early 1970s, there was overwhelming political support to
legalize abortion, and abortion rights activists specifically sought a
plaintiff so that a legal challenge to abortions could be argued in
court. The plaintiff, Norma McCorvey, was the “Jane Roe” for whom the
decision is named. The CDC defines an induced abortion as “a procedure
intended to terminate a suspected or known intrauterine pregnancy and
to produce a nonviable fetus at any gestational age.”
- Eroding abortion rights
- Although the fundamental right to have an abortion has remained
intact by basic statute, poor women have had their rights eroded by
the Hyde amendment in 1976 prohibiting the use of federal funds for
abortions except in the case of maternal life endangerment. This, in
conjunction with a rise in the takeover of hospitals in some regions
by religious organizations opposed to abortion as well as
contraception, has restricted access to abortion. Almost one third of
publicly funded recipients are prevented from having a termination by
lack of access to care. Public controversy has raged on the specific
question of whether individuals or institutions should be allowed to
refuse legal care. Although 45 states have enacted laws allowing such
refusal, only 5 also have enacted laws that require the provider to
notify patients of their refusal. These provisions extend to
contraceptive and sterilization services.
- The fetus can survive extrauterine life at term and with life
support in the mid second trimester. No definitive point exists at
which the fetus cannot survive, nor does a medically agreed upon, a
legislatively agreed upon, or a religiously agreed upon point at which
viability exists. Fetuses generally are considered viable after 27
weeks of pregnancy and not viable at less than 20 weeks of pregnancy.
- In a 1989 decision called Webster versus Reproductive Health
Services, the Court upheld the state’s right to determine viability
testing after 20 weeks of gestation, and in the legal preamble, the
wording states that life begins at conception. Other laws cover
similar legal concepts. In Planned Parenthood versus Casey, some
fetuses were recognized to never attain viability (anencephalics), and
in Colautti versus Franklin, the provisions are even broader,
recognizing that physician judgment may be the most important.
- For a listing of abortion-related historical facts see the Hope Clinic
for Women, History of Abortion.
- Although only 2% of the population verbalizes opposition to
abortion in any circumstance, wider political support exists for
abortion bans on late-term abortions or abortions performed in the
third trimester of pregnancy. Since advances in surgical techniques
have allowed for surgical terminations to be performed later in
pregnancy, another divisive factor has crept into the debate. Abortion
opponents have lobbied against specific procedures performed late in
pregnancy, and they have the stance that other techniques are
- By 1998, 28 states had passed bans on this procedure, referred to
in the lay press as a partial-birth abortion, which is the medical
procedure intact dilatation and extraction. The descriptive language
in the US Criminal Code, if passed, would make it illegal to
“deliberately and intentionally deliver into the vagina a living
fetus, or a substantial portion thereof, for the purpose of performing
a procedure the physician knows will kill the fetus and kills the
- President Clinton has twice vetoed the federal Partial-Birth
Abortion Ban Act on the grounds that the language is
unconstitutionally vague and provides physicians no clear direction in
how to apply the law. Oddly, physicians have been successfully sued
for failure to refer for late-term abortions in cases of fetal
abnormalities. The rationale for continued need for late abortions has
been argued thoroughly by David Grimes in The continuing need for late abortions.
- Since the time of Roe versus Wade, physicians, patients, and the
Supreme Court have repeatedly reaffirmed that the determination about
medical need, the choice of a procedure, and viability is best left as
a medical decision, not one for the legislature.
- Most young adolescents have parental or family involvement in
their decision to have an abortion. Adolescents who are older,
especially those living independently, often do not. In spite of ample
scientific evidence that the majority of teens seek parental
involvement and widespread legal concern that individuals who do not
seek parental involvement may be at risk physically or emotionally, a
barrage of legislation mandates that all minors seek parental consents
or that the parents be notified in advance of a minor child having an
- The laws that have enabled this to occur legally are backed in the
Supreme Court. By 1999, 38 states had such laws, and 29 states enforce
their laws. Currently only Connecticut, Maine, and the District of
Columbia have laws that affirm the rights of a minor to seek her own
abortion. For a summary of laws as of September of 2000 see Minors' Right to Consent to Health Care and to Make Other
Important Decisions. As a result, abortion providers in states
that do not require parental consent for minors have begun to see
adolescents that may travel hundreds of miles to seek an abortion.
- Patient rights bills have been developed by a variety of groups
including the Consumers’ Bill of Rights and Responsibilities that has
been developed by a presidential task force. These bills specifically
state that patients have a right to access knowledge, and that
providers have a right to discuss care they think is medically
appropriate regardless of the source of that care.
- Mandatory waiting periods
- Mandatory waiting periods mandate by law that the woman seeking to
terminate a pregnancy must first, in person, receive specific
information about the pregnancy and pregnancy alternatives.
- In spite of the fact that these laws typically only mandate a
short 24-hour waiting period, they have the effect of increasing the
percentage of second trimester abortions in states with these
- Advances in neonatal medicine with improved fetal survival very
early in gestation have fueled the abortion debate in the past 2
decades, overshadowing the continued cultural debate on beginning of
- Recently, the progress in using fetal tissue, fetal stem cells, or
even discarded embryos for research and medical treatments has kept
the debate both vocal and contentious. These therapies may be
indicated in the treatment of diabetes, Parkinson disease, kidney
disease, and cartilage diseases, among others.
- Current national regulations prohibit most fetal tissue research,
but the National Institute of Health (NIH) revealed late in the year
2000 that it will allow stem cell research.
- Many world cultures place a premium on male children, and reports
of selective abortion of female fetuses have continued to
- Most abortion providers are obstetricians and gynecologists.
However, providers from a variety of backgrounds (family
practitioners, nurses) can be taught to perform abortions safely.
Physicians generally are receptive to the concept of legal abortions
being available in the United States. Epidemiologic research shows
those most receptive tend to be non-Catholic and trained in a
residency program where abortion observation was a
- As providers have decreased in number, women are traveling farther
to obtain abortions, presenting later in pregnancy, and are unable to
obtain services if they are poor and live in most rural
- Posttraumatic stress has been reported in abortion workers exposed
to violent abortion protests at their clinics.
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