Suzanne R. Trupin
Approximately 1.18 million abortions were performed annually in the United States in 1997. This number has decreased from the 1.61 million abortions in 1990. Each year, 2% of women of reproductive age (15–44) terminate a pregnancy legally in the United States. With the rate of abortion in the 1980s, it was estimated that 43% of women in the United States would have a pregnancy termination at some point in their reproductive life. The most recently published rate of abortion is approximately 20 per 1,000 women between the ages of 15 to 44. This rate has decreased from 25 per 1,000 women in 1990. The abortion ratio is about 306 per 1,000 live births. This ratio has decreased from 345 abortions per 1,000 live births in 1990 (Table 31.1). Regardless of contraceptive availability, about half the 6 million pregnancies occurring each year are reportedly unplanned. Of the unplanned pregnancies, approximately half are terminated by induced abortion. This rate has remained fairly constant since 1980. The typical patient seeking an abortion has been young, white, unmarried, and poor. Statistics from 1972 are indicative of the period prior to Roe v. Wade and the legalization of abortion in the United States (Table 31.1 and Fig. 31.1, Fig. 31.2 and Fig. 31.3). Worldwide, 53 million abortions are performed annually with 20 million reportedly being done illegally. Illegal abortions remain very unsafe and may account for 50,000 to 100,000 deaths each year.
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TABLE 31.1. Legal abortions, abortion ratios, and abortion rates in selected years from 1972 to 1997 and characteristics of women who obtained legal induced abortions in those years |
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FIG. 31.1. Fertility rate and abortion ratio and rate, by year—United States, 1972–1995. (From Koonin LM, MacKay AP, Berg CJ, et al. Pregnancy-related mortality surveillance—United States, 1987–1990. MMWR CDC Surveill Summ 1997;46:10.) |
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FIG. 31.2. Abortion ratio (per 1,000 live births) by age group (in years) of women who obtained a legal abortion, selected states—United States, 1974–1997. (From: Koonin LM, Strauss LT, Chrisman CE, et al. Abortion surveillance—United States, 1997. MMWR CDC Surveill Summ 2000;49:1–11. |
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FIG. 31.3. Rate of induced abortion by gestational week for 1997. MMWR CDC Surveill Summ 2000;49:1–11. |
Abortion remains primarily a surgical procedure with 97% being done by suction curettage. The first medical abortion (in the U.S.) was done in the 1960s with antimetabolites. A medical abortion is accomplished by drug induction without primary surgical intervention. In September 2000, the U.S. Food and Drug Administration (FDA) approved a more effective yet more complex regimen, which includes mifepristone (initially developed under the manufacturer designation RU-486), an antiprogestin, as the initiating medication, followed by off-label use of misoprostol to be administered in the physician's office. Mifepristone, even if given with newer evidence-based medicine protocols using an equally effective 200-mg dose, carries a cost of $270 per 600-mg dose. This high cost has been one factor that has hampered the widespread use of this medical regimen for abortions. Nonetheless, about half of abortion providers were offering medical abortions within the first 6 months of 2001, and some centers reported that 10% to 15% of their terminated pregnancies were medical abortions. Drug protocols, with greater flexibility in dosage, timing of medication to decrease the interval from initiation to completion of the abortion, and home administration protocols to lower costs, will likely increase the number of providers offering medical abortions. These drug protocol modifications should also produce an overall shift from surgical to medical abortions.
LEGALIZATION
Since the landmark 1973 Supreme Court decision legalizing abortion, hundreds of laws, both federal and state, have been proposed or passed. This makes induced abortion the most actively litigated and highly publicized area in the field of medicine. The two most controversial topics of legislation involve debate on an appropriate definition for “viability” and the need for legislating parental involvement in a minor's decision-making process.
ABORTION COUNSELING
Some patients find the decision to have an abortion an easy one; for others it takes time and the consultation of a variety of providers and counselors. It may also take time to filter through multiple layers of providers to find a facility that performs pregnancy terminations, as over 80% of U.S. counties have no abortion providers. Statistics from the Alan Guttmacher Institute indicate that almost half of the women having abortions beyond 15 weeks of gestation state their procedure was delayed because of problems in funding or locating abortion services. Preoperative counseling for abortions should include a discussion of all options regarding the pregnancy within the context of the patient's concerns driving her decision to abort (Fig. 31.4). This should include discussion of medical versus surgical procedures, continuing the pregnancy, and the various options for legal adoption. Discussion should focus on the decision-making process and the patient's support system. Of utmost importance is to ensure that patients are not being coerced into their decision.
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FIG. 31.4. Most important concerns driving the decision to abort. (From Torres A, Forrest JD. Why do women have abortions? Fam Plann Perspect1988;20:169–176, with permission.) |
Counseling sessions should also provide medical information, review pertinent medical and gynecologic history, and specifically discuss any previous abortion procedures. Statistics show that 47% of women who have an abortion have had a least one previous abortion. Medical personnel, such as obstetricians, perinatologists, and nurses, should be enlisted to review medical risks and benefits within the context of the patient's medical and pregnancy history. Patients should be informed of the risks of the procedure selected, and full disclosure of information includes discussing the risks of the abortion process as well as the risks of continuing the pregnancy. A full disclosure of methods regarding surgical versus medical abortions is mandatory. If a surgical abortion is preferred, the patient must then understand that the procedure is most often done under local anesthesia. Because the patient is awake during the procedure, she may verbalize a change of intent at this time. If this occurs, consent must be reestablished before the abortion may proceed.
The medical abortion counseling process takes longer than the surgical abortion counseling session. In the event the patient chooses a medical abortion, a description of the FDA protocol or any other evidence-based protocol must be presented to the patient. The patient will need to sign the mifepristone medication consent form. If the patient's medical abortion process will differ from the process described in this consent form, she must fully understand the differences. The patient needs to clearly appreciate that the passage of fetal tissue will present with bleeding, cramping, nausea and, in some cases, vomiting. There will also be some pain with the procedure. Patients will be told that they will be provided with sufficient pain medication and antiemetics. The patient needs to be given clear instructions on how to insert the misoprostol dose vaginally and to be taught how to differentiate bleeding from hemorrhage. This disclosure of information must be part of the consent process. There is a 2% to 8% chance of an incomplete abortion, which would require a follow-up surgical dilation and curettage for completion. Counselors must, therefore, indicate to the patient that follow-up examination visit(s) is (are) encouraged to ensure the completion of the pregnancy termination and the health of the patient. Finally, patients undergoing a medical abortion need telephone access and, more importantly, assistance with transportation in the event of an emergency during the abortion process (i.e., hemorrhage). Providers need to comply with all relevant applicable local, state and federal laws and ordinances.
In conclusion, the intent of the counseling session is to make sure that as much information as possible is available to the woman requesting a pregnancy termination in order for her to make an appropriate, informed, and independent decision. Counselors need to remain involved in caring for the patient throughout the abortion process. Preabortion counseling should also explore the subjects of future contraception and protection against sexually transmitted diseases (STDs).
INDICATIONS FOR ABORTION
Medical Indications
Medical indications for abortion have narrowed with advances in perinatal care. If data are available for a given indication, most perinatologists and abortion counselors prefer to put the risks in statistical perspective. In particular, these professionals are opposed to the concept of “recommending abortion” even in cases where maternal death is a possibility. Induced abortion is safer, with respect to mortality and morbidity, than a term delivery. The relative risk of death associated with childbirth may be ten times higher than that associated with abortion although the absolute risks for either are low (Table 31.2). Medical abortions in early pregnancy circumvent surgical and anesthetic risks associated with either delivery or surgical abortion. However, there is no evidence in the literature that suggests this makes medical abortion safer than surgical abortions. In the 1980s, it was estimated that maternal mortality was reduced seven-fold by a first trimester abortion compared to women carrying their fetus to term. More recent data indicate that a first trimester abortion may be even safer now; consequently, any discussion of risk must always be put in perspective.
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TABLE 31.2. Case-fatality rates for induced abortion and pregnancy |
Maternal conditions that may be considered a medical indication for an abortion include: renal failure, diabetic retinopathy, sickle cell disease, cardiac disease, neoplasia, autoimmune disease, and psychiatric disease. Cardiac conditions that may result in maternal death include severe mitral stenosis, coarctation of the aorta with vascular involvement, uncorrected tetralogy of Fallot, aortic stenosis, previous myocardial infarction, myocardial infarction during pregnancy, artificial heart valves, and Marfan syndrome with aortic involvement. A cardiac anomaly with potentially greater mortality is the Eisenmenger syndrome with pulmonary hypertension. Other medical indications include intrauterine infections, chorioamnionitis, and preterm premature rupture of membranes. Radiation treatments, chemotherapy, and live virus immunizations given inadvertently in early pregnancy are other reasons to discuss the risks and options of an abortion. However, nondirective factual counseling in this area is essential.
Fetal Indications
Despite progress in prenatal diagnosis, most anomalies identified have no real means of treatment other than abortion or, otherwise termed, selective termination. Maternal–fetal surgery involves surgical correction of fetal anomalies in utero. These anomalies are more easily detected with newer ultrasound technology increasing fetal assessment capabilities. Yet, this type of surgery remains experimental and controversial with little long-term outcome data. At present, fetal indications for induced abortion include those anatomic conditions incompatible with life (e.g., anencephaly) and major congenital abnormalities (e.g., hypoplastic left heart, severe neural tube defects). Recent literature studied the most common indications for selective termination. Parents are more likely to electively abort if a central nervous system (CNS) anomaly was discovered in utero compared to a non-CNS anomaly (Table 31.3.). This was true for all grades of severity within the CNS anomaly classification compared to all grades of severity for the non-CNS anomaly classification.
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TABLE 31.3. Abortion rate, by maximum severity of non-CNS anomalies, CNS anomalies, and chromosomal abnormalities |
When an anomaly is diagnosed in time to have a legal abortion, 50% to 80% of women selected abortion, although even the most severe cardiac conditions can theoretically be treated by cardiac transplantation. Most serious anomalies are not diagnosed until well into the second trimester as that is when complete anatomic surveys, by ultrasound, are performed.
SURGICAL ABORTION
Preoperative preparation for most women, after the focused history and consent process, can be fairly simple. The pregnancy is assessed for gestational age. (The abortion facility must be capable of performing the procedure for the gestational age.) Evaluation includes adequate cervical visualization, uterine palpation, and whether a local or general anesthetic is required. Testing for STDs is considered optional but may be beneficial for patients at high risk for an STD. A targeted physical examination is sufficient for a healthy woman. Laboratory analysis must include assessment of the hemoglobin or hematocrit and establishment of a patient's Rh factor status. Pap smears are recommended per usual protocols but are not specifically necessary for the abortion.
Ultrasonography establishes the pregnancy dating, as well as confirming fetal number, placental localization, and the presence of any uterine anomalies or fibroids. Sonography can guide the performance of the procedure by continually imaging the instruments as they are being manipulated within the uterine cavity (Fig. 31.5). For very early terminations, so little placental tissue exists that postprocedure ultrasound imaging is not always helpful in confirming the completeness of the procedure.
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FIG. 31.5. Abdominal ultrasound anteroposterior view of 16-mm, straight vacuum curette visualized in an intrauterine location during a dilation and evacuation procedure for pregnancy termination. |
Anesthesia for first trimester and early second trimester procedures is typically local infiltration paracervically with lidocaine, 12 cc of 1% to 2%, or chloroprocaine, 12 cc of 1% to 2%, with the physician and an assistant speaking to the patient to relax and reassure her throughout the procedure. Approximately 80% of women receive only local anesthesia during surgical termination. Preoperative preparation may include acetaminophen, or a nonsteroidal antiinflammatory drug (NSAID) or diazepam. Conscious sedation can be provided with 2.5 to 3.0 mg midazolam. In addition, rapid-acting narcotics, such as fentanyl, are occasionally used.
Cervical Dilation
Forceful cervical dilation can cause cervical lacerations, damage, or permanent incompetence of the internal os, all of which are extremely rare with modern techniques. Early first trimester procedures often require no dilation for the multiparous patient and little dilation with primigravidas. Initially, 400 µg of misoprostol, a cervical dilating agent, may be administered orally a few hours prior to the surgery. For procedures performed at less than 9 weeks from the last menstrual period (LMP), dilation is accomplished with progressive use of graduated cervical dilators. Pratt-type or Teflon Denniston dilators 3 mm and larger, are used serially to enlarge the cervical canal. Beyond this gestational age, medical or mechanical aids for dilation are very helpful. Most commonly employed is the seaweed Laminaria japonica (in singles or multiples), which expands over a 3- to 24-hour period to enhance dilation. Successive applications of increasing numbers of L. japonica can be effective and used for longer than 24 hours. Once the dilators are inserted, patients should understand that the abortion process has begun and must be completed, and failure to do so can result in life-threatening infection. Failure to be able to dilate the cervix is rare, but if the os is so stenotic that it cannot admit even a 3-mm dilator, preoperative use of misoprostol 400 to 800 µg intravaginally or 200 to 400 µg orally, up to 24 hours prior to the surgical procedure, can be helpful. When the cervix is easier to dilate, be aware that misoprostol has a fairly rapid onset so its use, earlier than 4 to 6 hours prior to the procedure, may lead to a spontaneous pregnancy expulsion. Another option is waiting until the pregnancy progresses to a later gestational period when the cervix may be more easily dilated.
First Trimester Abortion Procedure
Early first trimester abortions are almost exclusively performed by suction curettage. The earliest surgical abortions are performed between 3 to 5 weeks after the LMP. In some institutions, early abortion is performed before sonographic visualization of the gestational sac, but most are performed after the intrauterine location of the pregnancy is confirmed by ultrasound.
To rule out ectopic pregnancy, two to three β-human chorionic gonadotropin (β-hCG) titers should be taken at 48-hour intervals. Beta-hCG titers greater than 2,000 IU/L for a patient without an intrauterine sac visualized sonographically suggest an ectopic gestation. A sonogram should again be performed to definitely ascertain presence or absence of an intrauterine gestational sac. If an ectopic pregnancy is still suspected, the woman may undergo a medical abortion using the methotrexate protocols, which will treat an ectopic pregnancy as well.
To begin the suction curettage procedure, the anterior lip of the cervix, optionally anaesthetized at 12 o'clock first, is grasped with a single-tooth tenaculum that effectively stabilizes the cervix and straightens the cervical–uterine axis to facilitate cannula insertion. Local anesthetic is circumferentially infiltrated submucosally in the paracervical region. The cervix is dilated commensurately with the length of gestation and the need of cannula aperture. For a 7- to 9-week post-LMP gestation, cannulas of 5 to 9 mm in width are used; they can be soft, flexible cannulas or rigid plastic, either straight or bent. Use of a uterine sound should be avoided, as it increases the incidence of uterine perforation, and depth of the endometrial cavity can be assessed by other means. The actual evacuation is accomplished by suction generated by a self-locking, handheld syringe or a machine aspirator; both may generate pressures of 60 to 70 mm Hg. Completeness of the procedure is confirmed by the appearance of bubbles in the suction cannula and the characteristic uterine sound of the catheter against the uterine wall, denuded of the decidual tissue. Completeness of the procedure can be confirmed by looking at the uterine cavity under ultrasound (Fig. 31.6A, Fig. 31.6B and Fig. 31.6C).
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FIG. 31.6. A: Longitudinal view of the uterine cavity within minutes after a surgical abortion showing the endometrial stripe and constricted endocervical canal. B: Transvaginal ultrasound image taken in a longitudinal view of an 11-week gestation 1 hour after uterine evacuation shows evidence of procedure completion, but the endometrial stripe is less prominent due to the natural accumulation of blood within the endometrial cavity. C: Two weeks after suction curettage, transvaginal endometrium shows 16 mm of endometrial tissue, likely to be decidua and a few chorionic villi consistent with the normal involution process and warrants observation if clinically stable. |
After the procedure, a surgeon can reliably confirm the pregnancy contents were obtained by inspecting the tissue. Washing the villi for the early suction curettage and then observing them through backlighting can enhance tissue visualization (Fig. 31.7). For procedures farther along in pregnancy, assessment of the primary skeletal fetal parts must be done. Visual confirmation of tissue must be done before the patient leaves the facility. Histologic evaluation of the products of conception can identify the rare woman with gestational trophoblastic disease (i.e., a molar gestation). In cases of known fetal anomalies, pathologic tissue examination is even more important. Blood loss is usually low, varying from 15 to 50 mL in most cases.
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FIG. 31.7. Transillumination of villi floating in saline allows visualization for placental tissue confirmation after pregnancy termination. |
Second Trimester Abortion Procedure
Dilation and Evacuation
Dilation and evacuation (D & E) is the most common method of second trimester abortion. The procedure requires additional dilation of the cervix (up to 2 to 3 cm), and some of the evacuation needs to occur with the use of Sopher and Beirer type forceps. The forceps are most safely manipulated in the lower portion of the uterus or the midcavity region. Occasional use of uterotonic agents enhances the ability to reach the products of conception. Blood loss with these procedures is typically in the 100- to 300-mL range. Vasopressin, 4U, added to the paracervical block, significantly reduces bleeding. The use of ultrasound during the procedure to ensure the forceps are within the uterine cavity and afterward to verify complete removal of the products of conception may be helpful.
Intact Dilation and Extraction
Procedures removing an essentially intact fetus have been termed intact dilation and extraction. Very few of these procedures have been performed in the United States.
Saline- and Prostaglandin-induced Abortions
After 16 weeks gestation, abortions can still be performed with intrauterine abortifacient injection. Several solutions have been used for intrauterine injections, including hypertonic glucose, saline, urea, or uterotonics, such as prostaglandins or oxytocin. The uterus is relatively resistant to oxytocin induction at this point in the gestation, thus high doses of oxytocin are typically required and even those may not cause adequate uterine contractions. Labor induction with prostaglandins is the preferred strategy for second trimester pregnancy evacuation. The most widely used prostaglandin is PGE2, dinoprostone, 20-mg suppositories, or 15-methyl-PGF2, carboprost 250 g and tromethamine, for intramuscular injection. Misoprostol protocols using 25 g to 800 g orally or intravaginally, 4 to 8 hours prior to the procedure, can speed up delivery, although this drug regimen alone may take 24 to 72 hours. As saline and urea are hypertonic, the instillation procedure kills the fetus. Isolated reports of fetal survival in cases of prostaglandin induction exist. To avoid delivery of a nonviable but living fetus, intracardiac injection of digoxin or potassium chloride can be given prior to induction. Induction techniques may offer some advantages for the postmortem evaluation of fetal anatomic abnormalities, but 97% of anomalies can be evaluated after D & E. Preoperative karyotyping through amniocentesis is the best assurance of accurate chromosomal evaluation as this avoids more terminal cell contamination (i.e., the deciduas) and the requirement for optimal handling of the tissue to maintain viability.
Hysterotomy
Hysterotomy may rarely be required for some cases of induced abortion. An indication for a hysterotomy would be large leiomyomata blocking cervical access. However, D & E procedures, even preceded by laminaria insertion, can safely be done in cases of placental previa as the laminaria do not need be inserted through the internal os to dilute the cervix. It is important to note that all hysterotomies are done with the classic uterine incision because the uterine segment is not developed well enough early in pregnancy to put the incision in the lower uterine segment.
Surgical Sterilization
At the time of first or second trimester induced abortions, bilateral tubal ligation (using minilaparotomy), tubal fulguration, or tubal device occlusion are all considered to be safe. This option should be discussed during preoperative counseling.
Postoperative Care
Antibiotic prophylaxis against infection reduces the incidence of postoperative salpingitis and endometritis, since cultures are not typically available preoperatively. Doxycycline has a broad spectrum of coverage and is the agent of choice. If the patient is allergic to doxycycline, metronidazole or ampicillin can be considered as alternatives. Prophylaxis regimens vary, but two doses of 100 mg of doxycycline should be administered with termination and again in 12 hours. Postoperative pain management is relatively straightforward. Contraction pain is usually mild and responsive to acetaminophen. An alternative regimen includes the use of NSAIDs. Both the acetaminophen and the NSAIDS, if over-used, can potentially mask a postoperative fever. Prior to the procedure, the provider must take note of the Rh(D) antigen status of the patient. Then immunoglobulin D must be offered to all Rh(D)-negative women. Rho(D) immunoglobulin should be administered to the Rh-negative patient on the day of the procedure or within 72 hours. For gestations less than 13 weeks, a dose of 50 µg is given. This amount is effective in preventing sensitization. For gestations ≥13 weeks, a dose of 300 µg is required. This dose may be excessive, but is considered the standard dose used in the United States.
An intrauterine device, or intrauterine system, can be inserted immediately after a first trimester procedure, although the expulsion rate is slightly higher than if it is inserted after complete uterine involution. Injections of the contraceptives medroxyprogesterone acetate or estradiol–medroxyprogesterone as well as inserting levonorgestrel implants can be done on the day of the procedure or within the next 5 days. Postoperative appointments, 1 to 3 weeks later, can ensure and confirm that the induced abortion has been completed, evaluate for complications, reassess psychological status, and continue contraceptive and gynecologic care. As the β-hCG has a long half-life, sensitive pregnancy tests may stay positive for weeks after an adequately evacuated pregnancy. However, compliance with follow-up visits is low due to a variety of factors. These include the distances patients have to travel, the fact that most women usually feel very well after their abortion, and the negative emotional response associated with a return to the site of the procedure. Women often seek care elsewhere but do not verbalize they had an abortion due to possible negative feedback.
MEDICAL ABORTION
Medical abortions can benefit a woman seeking pregnancy termination by increasing her control over the process and may allow abortions to be more widely available in terms of the number of physicians that could provide this service in their offices. Both providers and patients can be shielded from the highly politicized abortion debate, allowing women to have an abortion without delay compared to waiting for an assigned scheduled surgery. Medical abortion reduces the risk of cervical laceration and uterine perforation and eliminates any anesthetic risk. Three abortifacients are currently being used for medical abortions: Prostaglandins (misoprostol), antiprogesterones (mifepristone), and antimetabolites (methotrexate). Misoprostol has been reported to be a teratogen when used in the first trimester. The mechanism of misoprostol action may be due to alteration of transplacental oxygenation or possibly a direct effect of the drug. The most common anomaly reported is a frontal facial set of lesions, termed Möbius syndrome, but over two dozen healthy pregnancies have been reported after failed medical abortion regimens. Mifepristone may be a teratogen but its effects have not been well studied. Methotrexate is a potent teratogen and its use in the first trimester is associated with major congenital malformations.
The FDA-approved regimen is initiated with mifepristone, followed by misoprostol (Table 31.4). This protocol is for women up to 49 days from the first day of the LMP. The literature, establishing the safety and efficacy of procedures up to 63 days from the LMP, indicates the procedures are less effective at this time but safe if clinicians and patients completely understand the process and the need to intervene with surgical uterine evacuation when necessary. Although the counseling process has been reviewed earlier in this chapter, patients given methotrexate and misoprostol need to comprehend that neither medication has been formally approved for medical abortions.
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TABLE 31.4. U.S. Food and Drug Administration-approved mifepristone and misoprostol regimen summarized |
Misoprostol
Misoprostol, an E1 prostaglandin analog, is FDA-approved as a treatment to aid in the prevention of gastric ulcers in persons taking NSAIDs. For pregnancy termination, the pharmacologic consequence of misoprostol administration is two-fold, softening the cervix and causing uterine contractions. The strong uterine contractions aid in the expulsion of the intrauterine contents. Misoprostol has excellent absorption orally or with vaginal administration. Oral absorption peaks in 30 minutes and then significantly drops at 120 minutes. The vaginal absorption does not peak for almost an hour, but high levels are sustained. The primary side effects of misoprostol are nausea, vomiting, diarrhea, abdominal pains, chills, fever, and shivering (Table 31.5). Misoprostol has been used for well over a decade with the antimetabolite methotrexate for medical abortions based on evidence-based protocols. As a single agent, misoprostol is considered less than adequately effective in terminating a pregnancy. Contraindications to misoprostol are glaucoma, anemia, mitral stenosis, and hypersensitivity.
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TABLE 31.5. Medications used in pregnancy termination |
Mifepristone (RU-486)
In 1988, the French released the progesterone antagonist RU-486, later named mifepristone, a derivative of norethindrone, for use as an abortifacient. It was noted that efficacy was improved if mifepristone was given in combination with a prostaglandin analog. Mifepristone has a potent receptor affinity for the progesterone receptor and a less potent affinity for glucocorticoid receptors. Once bound, it does not activate the progesterone receptor, rendering the progestin receptor inactive, thus making it an effective antiprogestin. Many prostaglandin analogs have been successfully used worldwide, but the FDA, in approving the drug, specifically mandated the requirement for mifepristone administration to be in conjunction with the misoprostol. The fundamental principle is that progesterone support of trophoblast attachment to the decidua in early pregnancy is essential, and withdrawal of this support causes detachment. Once trophoblastic separation occurs, β-hCG levels will begin to decline. Mifepristone softens and dilates the cervix causing decidual necrosis, increasing uterine contractions, and enhancing the sensitivity of the uterus to prostaglandin administration.
Medical abortions have long been available in France, China, Sweden, and the United Kingdom. Before mifepristone was available for medical abortions in the United States, regimens in use worldwide varied. The FDA regimen specifies the dosage and timing of both the approved mifepristone and the misoprostol; the drugs are not currently individually approved for abortion (see Table 31.4). The regimen also specifies that the mifepristone is given on day 1 after the provider and the patient sign the informed consent. Then on day 3, misoprostol administration occurs in the provider's office with 4 hours of observation. The mifepristone must be directly purchased from the manufacturer after the provider signs a statement that he or she is capable of diagnosing an ectopic pregnancy and can arrange for the patient to receive a surgical abortion in the case that the medical abortion is not complete. Evidence-based medical abortion protocols provide equal efficacy with greater patient convenience and lower medical costs. Many regimens have been reported in the literature as shown in Table 31.6. The regimen most widely used is shown in Figure 31.8.
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TABLE 31.6. Efficacy of misoprostol regimens for medical abortion in the first trimester of pregnancy |
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FIG. 31.8. Nonsurgical evidence-based mifepristone/misoprostol abortion sequence. |
Patients undergoing medical abortion should be told to anticipate cramping, pain, and bleeding, and a third of patients may experience nausea, vomiting, diarrhea, dizziness, or fatigue (see Table 31.5). Abdominal/uterine cramping has been noted in 83% to 95% of patients; nausea has been observed in 12% to 61% of patients; vomiting in 9% to 47% of patients; diarrhea in 7% to 67% of patients; headache in 12% to 27%; dizziness in 1% to 37% of patients; chills in 14% to 89% of patients; mild to moderate pain in 50% to 95% of patients; and finally bleeding in 100% of patients. These symptoms are usually self-limiting and it is not necessary to treat them prophylactically. Narcotic-based analgesics are used, but many patients do well with NSAIDs.
The preabortion workup can be straightforward but should include a medical and obstetric history, allergies to medications, current patient medications, a pelvic exam, and a physical exam to obtain height and weight and blood pressure. All patients should be evaluated by pelvic ultrasound as all published studies to date have done this and it remains the standard of care. If a gestational sac is not seen, a clinical evaluation for an ectopic pregnancy should be initiated. A β-hCG titer of ≥ 2,000 IU/L and the absence of an intrauterine sac are consistent with either an ectopic pregnancy or an early spontaneous abortion. While patients could be treated based on β-hCG titers alone (without the use of ultrasound), misdiagnosis of an ectopic pregnancy may occur and this clinical regimen is not generally recommended. Finally, Rho(D) immunoglobulin for Rh-negative patients can be administered on day 1.
Methotrexate
Methotrexate is an antimetabolite that blocks dihydrofolate reductase, an enzyme essential for the production of the DNA nucleotide thymidine during DNA assembly. As rapidly dividing cells are most affected, it causes trophoblastic cell death. Methotrexate has been used clinically for the treatment of gestational trophoblastic disease (i.e., molar gestation, ectopic pregnancy, and early medical abortion). Although methotrexate is not FDA-approved for early medical abortion, the protocols for abortion have been extensively studied. Toxicity is dose-dependent, and in the dosages given for these regimens, blood levels of methotrexate are undetectable 2 days after administration. At the low doses used in regimens for ectopic pregnancy, side effects of methotrexate are primarily gastrointestinal, with nausea, vomiting, and diarrhea, although there have been isolated reports of marrow suppression (leukopenia) and alopecia (see Table 31.5). At high doses, methotrexate can cause renal toxicity or damage to the gastrointestinal lining. Methotrexate in the 50- to 150-mg range should not induce ovarian toxicity and has no known long-term toxicity with regard to reproductive function. The protocols with methotrexate are more complex than those for surgical abortions, requiring more evaluation and more provider visits (Table 31.7 and Fig. 31.9). Failure rates are marginally higher than with mifepristone/misoprostol protocols.
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TABLE 31.7. Methotrexate regimens used in pregnancy termination |
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FIG. 31.9. Nonsurgical methotrexate/misoprostol abortion. |
The National Abortion Federation (NAF) has revised the methotrexate/misoprostol protocol for early abortion. Two options have been recommended as guidelines for early medical abortion with these two abortifacients. Prior to the initiation of either of these protocols, counseling, education, and consent are completed. In addition, a medical history, physical exam, and sonography to confirm gestational age are necessary. The first option protocol begins on day 1 when methotrexate is administered. The dose can be 50 mg/m2 intramuscularly (i.m.) or 50 mg p.o. Rho(D) immunoglobulin for Rh-negative patients can be administered on day 1 also or can be given any day prior to the misoprostol administration. The patient is provided with sufficient analgesic information and prescriptions and is also provided with 800 µg misoprostol, with instructions for self-insertion vaginally on either day 3, 4, 5, 6, or 7. On day 8 the patient returns to the office for a visit and the patient history is obtained and ultrasound performed. With ultrasound, if a gestational sac is absent, treatment is complete. If a gestational sac is still present, repeat the misoprostol dose. This can be administered by the physician, self-administered in the clinic, or self-administered at home later that day. For follow-up, the cardiac activity in the gestational sac must be considered. If there is no cardiac activity in the gestational sac, the patient must return in 3 to 4 weeks. If there is cardiac activity, the patient should return in 1 week following this clinic visit. The visit on day 15 will include obtaining an interval history and an ultrasound. If a gestational sac is absent, the medical abortion is complete. If the gestational sac is present, with cardiac activity, a surgical evacuation is necessary at this time. If the gestational sac is present, with no cardiac activity, the patient should be given instructions on what to expect with regard to a delayed passage of the products of conception and scheduled for an appointment in approximately 3 weeks. On visit day 29 to 45 following methotrexate administration physicians must obtain another interval history and perform an ultrasound. If a gestational sac is absent, the treatment is complete. If a gestational sac is still present, a surgical evacuation is necessary at this time.
The other NAF-supported protocol is similar to the first protocol, but allows for an additional misoprostol administration (two 800 µg misoprostol doses total) for the patient (see Fig. 31.9). As a result, this may reduce the number of required clinic visits. Again this protocol begins on day 1 with 50 mg/m2 methotrexate given i.m. or 50 mg p.o. The Rho(D) immunoglobulin for Rh-negative patients can be administered on this day or any day prior to the administration of misoprostol. The patient is provided with sufficient analgesic information and prescriptions and two doses of misoprostol at 800 µg each with instructions for vaginal insertion on day 3 to 7. The second dose of the misoprostol should be administered 24 hours later if little or no bleeding has occurred after the first misoprostol dose. The day 8 visit is optional if the patient has had bleeding. If the patient has not had bleeding at this point, then the day 8 visit includes obtaining an ultrasound to determine the status of the gestational sac and provide the woman with support and reassurance that all is well. On day 15, if a complete medical abortion process has not yet taken place, an interval history is obtained and an ultrasound is performed. If a gestational sac is absent, the treatment is considered complete. If a gestational sac is present with cardiac activity, a surgical evacuation is required at this time. If a gestational sac is present without cardiac activity, the physician should make arrangements to follow up with this patient in 3 to 4 weeks. At this next visit, the patient should be given adequate information with regard to a delayed passage of the pregnancy. At a subsequent visit between day 29 and 45, if a completed abortion has yet to be confirmed, the physician must obtain the interval history and perform an ultrasound. If the gestational sac is absent, the medical abortion process is then complete. If a gestational sac is still present, a surgical evacuation is necessary at this time.
With these two protocols, some patients take as many as 4 weeks to complete the abortion, and 4% to 6% of women will require surgical evacuation of the products of conception. Complication rates are similar to those with the mifepristone/misoprostol regimen. Although the ultrasonography assesses the presence or absence of an intrauterine pregnancy, the patient must be continually reevaluated clinically for stability and amount of blood lost. Contraception counseling is always given upon the completion of any medical abortion.
Contraindications for Medical Abortion
Contraindications to mifepristone include anemia, adrenal disease or chronic corticosteroid use, severe liver, cardiovascular, kidney or pulmonary disease, clotting disorders, anticoagulation therapy, pregnancy with an intrauterine device, or hypersensitivity to this drug (see Table 31.5). Preprocedure assessment of a hemoglobin or hematocrit, as well as Rh typing is required. Rho(D) immunoglobulin is to be given on day 1 of the regimen if the patient is Rh-negative. Patient selection for medical regimens should focus on the certainty of the decision to terminate the pregnancy, a willingness to comply with the instructions, and access to 24-hour emergency services. Factors that may affect a patient selecting a medical abortion are a desire to avoid a surgical procedure, falling within the medical dating criteria for the procedure, having no medical contraindications to the medications, access to telephone and transportation, a good support system, the ability to return for follow-up visits, being able to tolerate pain as it may be intense when passing tissue products, and the ability to give informed consent.
Patient Follow-Up for Medical Abortions
Patients who are undergoing a medical abortion are told that they must expect bleeding and cramping, especially after misoprostol administration. About 5% of women abort in the first 24 hours after mifepristone alone. About another 5% of patients abort within a few hours of the misoprostol (day 3), and almost 80% of patients have aborted within the next 24 hours. Patients are asked, however, to be patient as longer times to completion do occur and are not accompanied by a greater risk of complications. Once the sequence of events in Figure 31.8 has begun, ultrasonography assessments are essential in visualizing completeness of the medical abortion procedure as shown in Figure 31.10A, Figure 31.10B, Figure 31.10C. At the 8- to 10-day visit, β-hCG levels may be measured. A decrease in β-hCG levels more than 50% has been shown to be associated with a complete abortion process. Sonography is performed and is necessary to confirm absence of gestational sac. Some publications have indicated that bleeding, on average, lasts 14 days. Yet, bleeding may persist for 60 days in some patients, without untoward effects. More important, the patient must realize that heavy bleeding and severe cramping does not necessarily indicate a complete abortion has taken place. Therefore, the patient must realize that a third follow-up visit (day 12 to 20) is compulsory to confirm the completion of the procedure and observe the absence of a gestational sac. Sonography is again used for this confirmation. A further decrease in β-hCG levels to more than 90% at this visit suggests, almost certainly, that the termination process is complete.
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FIG. 31.10. A: Transvaginal ultrasound of a 42-day pregnancy 4 hours after misoprostol ingestion. Heavy bleeding and passage of tissue indicated the pregnancy termination had probably completed, the ultrasound confirms the absence of a gestational sac and that the medical abortion was effective. B:Day 14 after a medical abortion of a 47-day pregnancy. Transvaginal ultrasound shows retention of gestational sac although no fetal development or fetal cardiac activity is seen. This is consistent with an incomplete medical abortion. Follow-up or surgical termination are both options if the patient is medically stable at this point. C: Three-and-a-half weeks after medical abortion of a 35-day pregnancy. Transvaginal ultrasound shows a sac in the endocervix, not in the uterine cavity. Abortion is not yet complete. |
In general, continuing pregnancy rates are low, and less than 1% of patients require curettage due to hemorrhage. However, one of the most important assessments the provider needs to ensure is a set of instructions for the patient to address severe bleeding. Because bleeding is expected, the provider needs to recognize, although rare, an actual episode of hemorrhage requiring surgery may be indicated. If the provider's bleeding threshold is low, it may be that potentially unnecessary surgical procedures are performed, and consequently an increased complication rate for the medical abortion procedure may result. Other indications for surgical intervention include a continuing intrauterine gestation of a retained nonviable pregnancy. A medical abortion is considered a failure if there is viable cardiac activity 2 weeks following the regimen. Additional rounds of misoprostol may be effective in accomplishing completeness at this time, but studies have yet to establish useful clinical guidelines. If the pregnancy is retained and nonviable, the patient will likely spontaneously abort within the next 3 weeks. Because there is always a risk, albeit low, of viable cardiac activity 2 weeks following the medical regimen, the provider must have arranged for a surgical evacuation as a back-up plan. It is important to note that surgical evacuation may be offered at any point in the medical abortion process if the pregnancy has not been spontaneously expelled and the patient is unwilling to wait any longer for completion.
COMPLICATIONS OF ABORTION
An induced abortion is a very safe procedure. Complications are rare (Table 31.8). During the abortion counseling session, the counselor should clearly state the known risks and benefits. The lay literature erroneously states that abortion causes cancer and reproductive dysfunction. Current medical evidence gives no indication that abortion causes either. There has also been no proven link between abortion and breast cancer. Future reproductive health is not affected by having a medically supervised legal abortion.
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TABLE 31.8. Complications of abortion and complication rates |
Surgical Procedures
Abortion procedures are extremely safe in the United States, with serious complications developing in only 1 in 100 patients and a mortality rate of less than 1 in 100,000 patients (see Table 31.2). The safest abortions are those performed at 7 to 10 weeks after the LMP (Table 31.9). Death rates for D & E have been reported at approximately 7 per 100,000, comparable to a term delivery. Concomitant sterilization, preexisting medical conditions, and general anesthesia may all contribute to an increase in postabortion complications. Immediate complications include acute cervical laceration, failure to dilate the cervix, failure to obtain the pregnancy tissue, postoperative pain, acute uterine hematometria, and, rarely, pulmonary embolism (Table 31.8 and Table 31.10). Other immediate complications can include moderate to severe pain, and allergic reactions to medications. More delayed complications include persistent bleeding secondary to retained products of conception, endometritis or salpingitis, and a continuing viable pregnancy. Longer-term complications include intrauterine adhesions and Rh sensitization. No long-term effects causing cervical incompetence have been documented in the literature. Rates of all the complications are extremely low.
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TABLE 31.9. Mortality rate with respect to gestational age |
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TABLE 31.10. Abortion-related deaths: United States 1987–1990 |
Uterine Hemorrhage
Rates of uterine hemorrhage (more than 500 mL blood loss) are low, occurring in less than 5% of cases, and the need for transfusion is exceedingly rare. Uterine atony can be decreased by complete evacuation of the uterus with the use of vasopressin injection in the paracervical block (4 U or 0.2 mL), or use of postoperative oral or intramuscular methylergonovine maleate (0.2 mg). Failure to respond to acute management of bleeding can be treated with carboprost tromethamine, oxytocin, or misoprostol. Continued atony can be treated with insertion of a large intrauterine Foley balloon to tamponade the uterine cavity.
Uterine Perforation
Uterine perforation is uncommon, occurring in approximately 1.3 in 1,000 terminations. It is usually not recognized even by an experienced surgeon at the time of the procedure. In first trimester fundal perforations, observation is all that is required. If the nature and extent of the perforation are unknown or if suction was applied during the perforation, evaluation by laparoscopy is necessary. In early first trimester abortions the procedure may be safely completed, even after perforation in experienced hands with sonographic guidance of the catheters. A perforation during D & E is a more serious complication, and the amount of bleeding may necessitate a laparotomy for uterine wall repair. One study from the literature established that 14 of 15 perforations during D & E were associated with major organ injury. Organs damaged include the uterus, bowel, and bladder. Surgical interventions, when necessary, should not be delayed.
Endometrial Adhesions
Asherman syndrome, or the development of endometrial surface adhesions or scaring, should be suspected in a patient with no menses for several cycles following a surgical abortion. This is a rare complication and may be avoided through the prevention of endometritis. This is done by complete evacuation of the products of conception.
Retained Tissue
Evaluation of the products of conception at the time of abortion can significantly reduce the number of cases of retained tissue. There have been case reports of very delayed retention of incompletely removed tissue, but a new pregnancy must be the first consideration in these cases. Persistence of a positive pregnancy test can signal retained products of conception, but careful postoperative evaluation by those experienced with the normal involution process typically reveals that this is a self-limited process. Normal resolution of the pregnancy test depends on the length of the pregnancy at the time of abortion and the sensitivity of the β-hCG tests used. Beta-hCG persistence for a few weeks is not uncommon. A rapid decline in the quantitative β-hCG is the rule. Sonography can be helpful, but many pregnancies have some intrauterine fluid accumulation that appears within a few hours of abortion and does not dissolve for several days in a first trimester pregnancy. Retained products of conception may be most effectively handled by endometrial aspiration (3- to 5-mm suction pipettes), which is also useful for treatment of hematometria and can be diagnostic for retained tissue. Alternatives that may be useful in selected cases are observation, uterotonics (with methylergonovine maleate or misoprostol), or repeat suction curettage. In some cases, the retained tissue can cause uterine hemorrhage and increase the incidence of infection.
Infectious Complications
Endometritis can occur with or without retained products of conception. Clinical signs are abdominal pain, increased cramping, fever, and increased bleeding. Endometritis is difficult to diagnose but can be presumed to be present when tenderness, especially associated with febrile morbidity (fever >38°C), or an elevated white blood cell count is present. It is expected to occur in about 0.5% of suction curettage procedures, 1.5% of D & E procedures, and 5% of uterine instillations, despite the use of prophylactic antibiotics. The organisms most likely responsible for endometritis are vaginal flora. A broad-spectrum oral antibiotic with anaerobic coverage is usually sufficient therapy. Repeat curettage may be indicated when it seems likely that retained products of conception are responsible for the endometritis.
Complications of Medical Abortions
Complications due to medical abortions exist but are rare. The most common complication from a medical abortion procedure is an incomplete abortion. Surgical evacuation is then required to complete the procedure. The incidence of hemorrhage is less than 1%. Bleeding from a medical abortion procedure can be heavy but only in rare instances does this bleeding become so severe that transfusion is warranted. In some instances, copious amounts of bleeding may need treatment with vasoconstrictor medications, curettage, and saline solution administration. More often less serious complications arise as indicated in Table 31.5. The incidence of intrauterine infection after surgical abortions is 0.1% to 5%, likewise infections after medical abortions are rare, occurring 0.09% to 0.5% of the time. Patients having experienced both medical and surgical abortion report greater satisfaction with the low risk of complications associated with medical abortion protocols.
Psychological Consequences of Abortion
Improvement in emotional health is the most common psychological consequence following abortion. However, women with a prior mental health diagnosis of depression may be at risk for depression following an induced abortion. The proportion of women experiencing clinical depression, up to 2 years after the induced abortion, is not significantly different from the population in general for this same age group (approximately 15–35 years old). Although occasional reports of posttraumatic stress disorder are documented, the incidence of posttraumatic stress disorder in the postabortion population is less than in the general population for this age group. There is a subset of patients who do feel sadness, guilt, and regret after an abortion. Studies show this subset of patients to be 10% to 30% of all women who have experienced an abortion, but these feelings are usually mild. It is the job of abortion providers to be sensitive to the emotional support requirements for each woman undergoing pregnancy termination. Preabortion counseling should increase awareness for all patients with regard to their possible feelings after the abortion. Younger women (<24 years old) and women who have other children may be at higher risk for feelings of regret and distress after an abortion. It has also been noted that emotions of regret, sadness, and guilt may increase over time (years after the abortion). But whether these feelings were due directly to the abortion years before, or from another completely different emotionally draining event occurring since the abortion procedure, is difficult to ascertain.
SUMMARY POINTS
· An estimated 1.2 to 1.6 million elective abortions have occurred in the United States in each of the past 10 years, making this a very common procedure and choice for women with unwanted pregnancies.
· Extensive research indicates that induced abortions continue to be requested by women regardless of religious conviction or socioeconomic status.
· The most common surgical approach in the first trimester is suction curettage and in the second trimester, dilation and extraction.
· Medical abortion is performed by initial administration of mifepristone followed by misoprostol. A non-FDA approved alternative is the use of methotrexate.
· The complications of induced abortion are relatively few and the death rates remain less than 1 woman per 100,000, comparing favorably to maternal mortality.
· It is important for health care providers to understand the process of induced abortion and to recognize and be able to counsel women regarding the potential risks, benefits, and complications of both surgical and medical abortion procedures to keep these procedures safe and widely available.
SUGGESTED READINGS
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