Elective Abortion

Surgical termination

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 Terminations performed in this very early time frame have been termed menstrual extractions, a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed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

Abortions performed prior to 9 weeks from the last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.

The following methods are available for surgical abortion:

• Manual vacuum aspiration (menstrual extraction) is used at 4-10 weeks' gestation and is 99.2% effective.

• Suction curettage is used at 6-14 weeks' gestation.

• Sharp curettage alone is not recommended due to risk of increased blood loss, adhesive disease and retained product of conception (POC) compared with suction.

• Dilation and extraction (D&E) is used at 14-24 weeks' gestation.

• Intact dilation and extraction (D&X) is used at more than 18 weeks' gestation, but is not performed in the US without prior feticide treatments due to current laws.

• Hysterotomy is used at 12-24 weeks of gestation and is reserved for the rare instances in which all other methods of abortion have failed or are contraindicated.

• Hysterectomy is reserved for rare instances in which other gynecological pathology dictates removal of the uterus.

Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 89% occur in the first 12 weeks., As of 2011, medication abortion accounted for 23% of all abortions, an increase from 6% in 2001. ^[9]

In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. Hysterectomy/hysterotomy procedures have the highest risk of complications but may still have a role in very rare clinical situations (eg, stenotic cervical os, placenta accreta). D&E is considered the safest form of abortion in the second trimester.  Little published data exist regarding the frequency or complication rates for D&X. A retrospective study has shown comparable complication rates and obstetric outcomes between these 2 procedures when performed by experienced physicians. ^[10]

Labor induction methods have an increased risk of complications such as retained placenta as compared with that of D&E. ^[11] The Society of Family Planning released second trimester induction guidelines in February of 2011. ^[12]

Women with a history of prior cesarean delivery are at increased risk of morbidity/mortality when undergoing labor induction as a form of surgical abortion. Labor induction has been associated with an increased odds ratio of uterine rupture and risk of blood transfusion in women with a history of prior cesarean delivery as compared with those without a uterine scar. Women with a history of a prior cesarean delivery may safely be offered D&E by a trained provider without increased risk.

Medical termination

Medical abortion is a term applied to a medication-induced elective abortion. This can be accomplished with a variety of medications administered either singly or in succession. Medical abortion with the combination of mifepristone and vaginal or buccal misoprostol has a success rate of 93-95% at up to 63 days' gestation. Ongoing pregnancy is rare, occurring in < 0.4% of patients. It is more common, occurring in 3-5% of patients, to have retained products, and these patients often require a suction procedure owing to ongoing symptoms. ^[13] Research continues to be performed to more clearly establish which protocol is best, which medications are preferable, and best methods to diagnose a complete versus an incomplete abortion.

Although a critical shortage of providers exists who can provide surgical abortions, in a study by Koenig et al, providers who do not perform surgical abortions have indicated a willingness to provide medical abortions. ^[14]

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

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

Medical abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed, the standard has been that the patient must be seen for evaluation of the completeness of the process. Many providers have also routinely used ultrasonography to assess abortion outcome. However, a study showed that using a low-sensitivity pregnancy test and clinical examination is sufficient for completeness assessment. ^[15]

The medical regimens initiate the process with progesterone receptor blockage by mifepristone without activating the receptor. This leads to a progesterone effect withdrawal from the decidua with ensuing necrosis and eventual detachment of the placenta at its implantation site. Following this with a prostaglandin, usually misoprostol, then leads to uterine activity and expulsion of the products of conception. It works best up to day 49 of pregnancy and regimens up to day 63 are effective as well.

A rare and serious infection of Clostridium sordellii is related to medical abortions. Four deaths associated with this infection have been reported since 2001. Fatal infections are rare, occurring in fewer than 1 in 100,000 uses of mifepristone medical abortions, which is far less fatal than penicillin-induced anaphylaxis (1 in 50,000 uses). Few direct comparisons of surgical and medical abortions are available, but using the data from the distributor of the mifepristone, 11 pregnancy-related deaths occurred in 1.8 million medical terminations from approximately 2000-2011, with a mortality rate of 0.7/100,000, which is virtually identical to the rate of mortality from surgical abortions. Because published data do not support a specific link between clostridial organisms and medication abortion, the American College of Obstetricians and Gynecologists (ACOG) does not recommend the routine use of prophylactic antibiotics for medication abortion. ^[16]

United States statistics

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

Each year, 1.7% of U.S. women aged 15-44 have an abortion.  Half have had at least one prior abortion.  89% of abortions occur less than 12 weeks gestation. ^[9]

International statistics

Globally, abortion mortality accounts for at least 13% of all maternal mortality. New estimates are that 50 million induced abortions are performed each year in developing countries, with approximately 20 million of these performed unsafely because of conditions or lack of provider training.  Up to 44,000 abortion related deaths occurred in 2014. While in the United States, only 1% of abortions are performed by induction, globally about 16% of all abortions, some as early as 12 weeks of gestation are performed by labor induction.

Race- and age-related demographics

Unintended pregnancy rates are 36% among non-Hispanic White women, 30% among non-Hispanic Black women, and 25% among Hispanic women. ^[17]

Women in their 20s account for more than half of all abortions. Eighteen percent of US women who obtain an abortion are teenagers. Although abortion rates are lower for women aged younger than 20 years and older than 40 years, these women are far more likely to have a pregnancy termination if they become pregnant. ^[17]

Fertility is not impaired. Prognosis is excellent.

Morbidity/mortality

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

Mortality rates are highest with the most invasive procedures and with increasing gestational age, as follows: 0.4 of 100,000 cases at less than 8 weeks of gestation, 3 of 100,000 cases at 13-15 weeks of gestation, and 12 of 100,000 cases at more than 21 weeks of gestation. Causes of death include infection, hemorrhage, pulmonary embolism, anesthesia complications, and amniotic fluid embolism. Death rates with hysterotomy/hysterectomy are 64.9 of 100,000 cases at 13-15 weeks of gestation and 123 of 100,000 cases at more than 21 weeks of gestation.

Complications of surgical abortion vary with the technique used, training of the provider, and the gestational age of the pregnancy. In general, the more advanced the gestational age at abortion, the higher the complication rate, and the more invasive the operative procedure, the higher the complication rate.

First-trimester abortion

Complication rates are low: 0.071% for hospitalization and 0.846% for minor complications. Abortion complications requiring hospitalization include incomplete abortion (0.028%), sepsis (0.021%), uterine perforation (0.009%), vaginal bleeding (0.007%), inability to abort (0.003%), and combined pregnancy (0.002%). Minor abortion complications include infection (0.46%), repeat suction (0.18%), cervical stenosis (0.016%), cervical tear (0.01%), seizure (0.004%), and underestimate of dates (0.006%).

Manual vacuum aspiration has the following complication rates: infection, 0.7%; perforation, 0.05%; retained POC, 0.5%; and repeat aspiration, 0.5-0.25%.

Second-trimester abortion

In D&E and D&X, the skill and experience of the physician are the most important factors in maintaining a low complication rate. Complication rates are low but increase with gestational age. Abortion complications requiring hospitalization include perforation, hemorrhage, infection, retained POC, and inability to complete abortion. Overall rates of hospitalization are 0.6% at 13 weeks of gestation and 1.4% at 20-21 weeks of gestation. Coagulopathy is a rare complication in D&E, occurring in 191 of 100,000 cases.

Avoid complications by obtaining adequate cervical dilatation through using passive dilators in abortions at 14 weeks of gestation and longer and by using double placement of passive dilators at longer than 20 weeks of gestation. Have appropriate instruments available for morbidly obese patients because standard instruments may not be long enough. Match the surgeon's skill and experience to the gestational age of the pregnancy to be terminated. Choose an inpatient setting for patients with severe medical conditions, anemia, placenta praevia (or other abnormal placentation), pelvic masses or large leiomyomas, or vein problems (eg, no intravenous access).

Uterine hemorrhage

Hemorrhage can be caused by atony, retained products, or perforation. Hemorrhage has been defined in a variety of ways, and the need for transfusion is exceedingly rare. If uterine hemorrhage rates include hemorrhage immediately postabortion, uterine atony rates of hemorrhage are as low as 5%. Initial hemorrhage should be evaluated by ensuring complete uterine evacuation.

General anesthesia increases the risk of atony. Blood loss of more than 300 mL in the first trimester is considered excessive. The next steps are typically medical in nature, ie, the use of intramuscular Methergine at 0.2 mg, the use of misoprostol 800 mcg placed rectally. Hemabate is also helpful. Treatment also can include uterine massage medications, removal of retained products, and repair of perforation as indicated. In the past, uterine packing has been used, but this can be accomplished effectively with the intrauterine inflation of a Foley balloon. Balloons of 5 mL can be inflated with 30 mL, or 30-mL balloons can be inflated with up to almost 100 mL of sterile saline. The inflation should correlate with uterine size. Now a Bakri Balloon designed for post abortion or postpartum hemorrhage can be used.

Uterine artery embolization can be used if placenta accreta is encountered, but very few of these procedures have been performed and statistical success rates are impossible to evaluate. If ineffective, hysterectomy should be performed as a life-saving measure.

Damage to cervix

The risk of cervical damage is increased with previous surgery to the cervix or laceration. Damage can be associated with forceful dilation with metal dilators and may be associated with damage to cervical vessels, with hemorrhage and parametrial hematoma formation. Repair damage using a transvaginal approach or laparoscopy/ laparotomy. Prevent damage by avoiding forceful dilation. Passively dilate the cervix using passive dilators and/or prostaglandin analogues. Delay the procedure if adequate dilation is not achieved.

Uterine perforation

Perforation has been estimated to occur in 1 per 250 cases. They are usually fundal and recognized by the provider at the time of the procedure. In a study by Pridmore and Chambers of 13,907 women who underwent outpatient termination of pregnancy, the perforation rate was 0.05% and, in the second trimester, ie, procedures from 13-20 weeks, the perforation rate was 0.32%. ^[18]

Risk factors for perforation are previous terminations of pregnancy, lower-segment cesarean deliveries, and loop electrosurgical excision procedures of the cervix. The common denominator is thought to be scarring of the internal cervical os.

Fundal perforations only require observation. If the extent of the perforation cannot be determined, if the patient is medically unstable, if the suction was applied at the time of the perforation, or if bowel or fat content was obtained by forceps at the time of a perforation, surgical evaluation of the patient is necessary. The surgical evaluation may be performed by an experienced laparoscopist or by laparotomy.

Perforation can occur with sound, dilators, curette, suction tip, forceps, or passive dilators. Increased risk is associated with previous surgery or laceration involving the cervix, previous uterine surgery, and grand multiparity. In the first trimester, most perforations are in the body of the uterus. Perforation can be recognized when an instrument passes endlessly, heavy or persistent vaginal bleeding occurs, signs of peritoneal irritation appear, or fat or other tissue appears in the specimen. If perforation is made with the sound or dilator, stop the procedure and observe the patient for a minimum of 1 hour. Antibiotic prophylaxis and ultrasonography are options. Reschedule the procedure to be performed in 2-3 weeks. If perforation occurs with suction tip or curette, stop the procedure. Options include observation if the patient is stable and the abortion is complete, laparoscopy if hemorrhage is suspected or the abortion is incomplete, and laparotomy if the patient is unstable.

Retained products of conception

Evaluation of the obtained products of conception at the time of abortion and postabortion uterine scanning have reduced the retained products of conception rate to less than 1% of cases. In one series reported by Hakim, Tovell, and Burnhill of 170,000 cases, only 0.5% incidence occurred in the first trimester. ^[19]  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. ^[20]

Cases of delayed bleeding, even after a normal cycle, have been reported. Dilatation and curettage or hysteroscopy are necessary if bleeding is brisker or if the amount of tissue is determined by sonographic evaluation to warrant more extensive procedures.

Endometritis and pelvic inflammatory disease

Infections postabortion are rare, occurring in fewer than 1% of cases. These are usually due to preexisting infections, such as bacterial vaginosis, cervicitis or salpingitis, or a failure of antibiotic prophylaxis.

Fever greater than 102°F (39°C) within 72 hours of the abortion should be considered septic abortion due to retained products. Treatment requires reaspiration followed by intravenous antibiotics (cefoxitin, clindamycin, chloramphenicol, cephalosporin with ampicillin, or penicillinase-resistant penicillin). Fever less than 102°F (39°C) should be treated with reaspiration and oral antibiotics (doxycycline 100 mg bid for 10 d).

The usual criteria should be used for the diagnosis of pelvic inflammatory disease (PID). The Centers for Disease Control and Prevention provides treatment guidelines as well as self-study and ready-to-use modules for clinicians at their Pelvic Inflammatory Disease (PID) Treatment Webpage.

Fatal toxic shock

Rapidly progressing toxic shock due to the endotoxins produced by Clostridia species bacteria has been reported 7 times (for a rate of 1 per 750,000).

Coexistent ectopic pregnancy

Residual positive hCG titers are not uncommon, and clinicians need to be vigilant in their evaluation of persistent positive pregnancy test results to avoid missing an ectopic pregnancy.

Pelvic ultrasonography is the most helpful tool. The presence of significant tenderness during the postoperative examination, a history of continued pain, and the elevation or plateau of hCG titers should raise concern. Coexistent intrauterine and extrauterine pregnancies are observed only in extremely rare cases.

Asherman syndrome

Postabortion uterine synechiae (or adhesions) that can obliterate part or all of the endometrial cavity have been reported. This is thought to be more likely secondary to endometritis than the instrumentation of the uterus, but sharp curetting after the abortion procedure should be avoided to avoid denuding the basal layer of the endometrium.

The diagnosis is made based on hysteroscopy or hysterosalpingogram findings in a patient who presents with postabortion amenorrhea.

Delayed sequelae

Abortion-related hemorrhage due to retained tissue can occur up to several weeks after the procedure. In general, blood loss in excess of that of a normal menstrual period is considered significant and should prompt reaspiration.

Few long-term sequelae of abortions have been documented. Both studies of first trimester surgical and medical abortion found that risks of ectopic pregnancies and spontaneous abortions in future pregnancies were not increased. Some studies have suggested an association between induced abortion and subsequent preterm birth and low birth weight.  However, these studies have been retrospective and unable to adequately adjust for confounders also contributing to these outcomes. Although a syndrome of posttraumatic stress has been reported, the literature has not been able to separate the stressors of the patient's social situation that lead to the abortion from the abortion procedure itself.

Although initial studies indicated a greater risk of breast cancer with elective termination than with term birth, a prospective cohort study indicates that no link exists between induced abortion and breast cancer. A prospective study (the Nurses' Health Study II) examined the association between induced and spontaneous abortion and the incidence of breast cancer. Most of the early data has been refuted.

Psychologic consequences of abortion

Generally, the psychological health of the abortion patient parallels her psychologic health prior to seeking an abortion. If the woman needed to have the abortion in secrecy, then long-term psychologic sequelae, such as intrusive thoughts, are more common.

Many studies have actually demonstrated improved psychological well-being after abortion. For the studies that have shown this, the improvement in psychological health is suggested to be more reflective of the patient dealing with the social issues that led her to select abortion.

Sometimes, confusion over normal emotions, such as sadness and grief versus psychological illnesses (eg, depression), seems to occur. The most common feeling experienced after an abortion is that of relief and confidence in the decision. Few women may experience feelings of grief and guilt postabortion, and these feelings usually pass within days to weeks in most cases and do not lead to psychological sequelae. One study demonstrated that the risk for serious psychiatric illness postabortion was 1%, whereas with live birth it was 10%. Considering that more than 1.5 million abortions are performed in the United States each year, if an epidemic of psychiatric sequelae due to the procedure occurred, it would be observed by now.

Many confounding factors are involved in a women's emotional status during the time of her abortion. Relationships, religion, age, social support, and previous psychological stability all play a part.

An entirely new set of circumstances and feelings exist in cases of rape and incest. These are often psychologically complex situations and unique to each case.

Providers can help women through abortions by presenting options and explaining the procedures. Counseling with a trained professional occurs before the abortion. This is a good time to identify factors that might lead to a patient having troubling feelings after the abortion. Some factors are low self-esteem, preexisting or past psychological illness, lack of emotional support, and past childhood sexual abuse. The counselor can then confront these issues before the procedure and help the patient assess specific needs and improve coping strategies.

Give patients information about abortion and postabortion care. Educate patients about birth control options, and discuss when to start birth control postabortion.

Because most terminations of pregnancies in the United States are performed on unintended pregnancies, counseling regarding fertility and contraceptive management are mandatory. In 83% of women, ovulation occurs in the first menstrual cycle postabortion. In first-trimester abortions, contraception should be initiated immediately postoperatively. Intrauterine devices (IUDs) can be safely inserted at the time of the abortion procedure.

For patient education resources, see Pregnancy Center as well as Abortion, Miscarriage, and Dilation and Curettage (D&C).