Abortion (Termination of Pregnancy)

What Is It?

Abortion is the removal of pregnancy tissue, products of conception or the fetus and placenta (afterbirth) from the uterus. The terms fetus and placenta usually are used after eight weeks of pregnancy, while the other terms describe tissue produced by the union of an egg and sperm before eight weeks. Each year approximately 1.2 million women in the United States choose to end a pregnancy. Other terms for an abortion include elective abortion, induced abortion, termination of pregnancy and therapeutic abortion.

What It's Used For

In the United States, abortion is used most often to end an unplanned pregnancy. Unplanned pregnancies happen when birth control is not used, is used incorrectly or fails to prevent a pregnancy. Abortion is also used to end a pregnancy when tests reveal that the fetus is abnormal. Therapeutic abortion refers to an abortion recommended when the mother's health is at risk.

Roughly one-half of all abortions are done during the first 8 weeks of pregnancy and about 88% during the first 12 weeks of pregnancy.

Preparation

Your doctor will ask about your medical history and examine you. Even if you used a home pregnancy test, another pregnancy test often is needed to confirm that you are pregnant. In some cases, you will need an ultrasound to determine how many weeks into the pregnancy you are and the size of the fetus, and to make sure the pregnancy is not ectopic. An ectopic pregnancy is one that is growing outside of the uterus. An ectopic pregnancy usually occurs in the tube that carries the egg from the ovary to the uterus (Fallopian tube) and is commonly called a tubal pregnancy.

A blood test will determine your blood type and whether you are Rh positive or negative. The Rh protein is made by the red blood cells of most women. These blood cells are considered Rh positive. Some women have red blood cells that do not produce Rh protein. These blood cells are considered Rh negative. Pregnant women who have Rh-negative blood are at risk of reacting against fetal blood that is Rh positive. Because a reaction can harm future pregnancies, Rh-negative women usually receive an injection of Rh immunoglobulin (RhIg) to prevent Rh-related problems after miscarriage or abortion.

How It's Done

Doctors can use medications, surgery or a combination of both to end a pregnancy. The method depends on how far along in the pregnancy you are, your medical history and your preference. Abortions during early pregnancy, before 9 weeks, can be done safely with medications. Abortions between 9 and 14 weeks usually are done surgically, although medications may be used to help soften and open the cervix. After 14 weeks, abortions can be done using labor inducing medications that cause uterine contractions or by using these medicines in combination with surgery.

Medical abortion
Abortions completed with medication, called medical abortions, are done within 49 days from the start of the pregnancy. Pregnancy usually starts two weeks after the first day of a menstrual period, so this corresponds to nine weeks from the last menstrual period. Medications used to induce abortion include:

• Mifepristone (Mifeprex). Known as RU-486, mifepristone is taken orally as a pill. Approved for use in the United States in 2000, this drug counters the effect of progesterone, a hormone necessary for pregnancy. More than 3 million women in Europe and China have received this drug to end a pregnancy.

  Side effects include nausea, vomiting, vaginal bleeding and pelvic pain. These symptoms usually can be treated with medications. In rare instances, there may be heavy bleeding. In that case, you may be admitted to a hospital and given blood transfusions.

  Mifepristone is more effective when another medication, such as misoprostol (Cytotec), is taken 24 to 48 hours later. It causes the uterus to contract. Between 92% and 97% of women who receive mifepristone in combination with, or followed by, misoprostol have a complete abortion within 2 weeks.

• Misoprostol (Cytotec). Misoprostol is almost always used in conjunction with mifepristone to induce a medical abortion. Misoprostol is a prostaglandin-like drug that causes the uterus to contract. One form can be taken by mouth. The other is inserted into the vagina. The vaginal form is less likely to cause diarrhea, nausea and vomiting. However, the vaginal form is associated with a higher risk of infection. To decrease the risk of infections, many doctors now prefer the oral form of misoprostol, followed by a 7 day course of the antibiotic doxycycline.

• Methotrexate. Methotrexate is used less often since the U.S. Food and Drug Administration (FDA) approved mifepristone. However, methotrexate may be used in women who are allergic to mifepristone or when mifepristone is not available. Methotrexate usually is injected into a muscle. Between 68% and 81% of pregnancies abort within 2 weeks; 89% to 91% abort after 45 days. Methotrexate is the medication most often used to treat ectopic pregnancies, which are implanted outside the womb. It kills the fast-growing tissue of ectopic pregnancies. When doctors give methotrexate to treat ectopic pregnancy, pregnancy hormone levels must be monitored until levels are undetectable in a woman's bloodstream. This monitoring is not necessary when methotrexate is used for medical abortions, where the pregnancy is known to be implanted in the womb.

In rare instances when a pregnancy continues after the use of these medications, there is a risk that the baby will be born deformed. The risk is greater with the use of misoprostol. If the pregnancy tissue does not completely leave the body within two weeks of a medical abortion, or if a woman bleeds heavily, then a surgical procedure may be needed to complete the abortion. Approximately 2% to 3% of women who have a medical abortion will need to have a surgical procedure, usually suction dilation and curettage (D and C), also called vacuum aspiration.

A woman should not have a medical abortion if she:

• Is more than 49 days pregnant
• Has bleeding problems or is taking blood thinning medication
• Has chronic adrenal failure or is taking certain steroid medications
• Cannot attend the medical visits necessary to ensure the abortion is completed
• Does not have access to emergency care
• Has uncontrolled seizure disorder (for misoprostol)
• Has acute inflammatory bowel disease (for misoprostol)

Surgical abortion

• Menstrual aspiration. This procedure, also called menstrual extraction or manual vacuum aspiration, is done within one to three weeks after a missed menstrual period. This method can also be used to remove the remaining tissue of an incomplete miscarriage (also called a spontaneous abortion). A doctor inserts a small, flexible tube into the uterus through the cervix and uses a handheld syringe to suction out the pregnancy material from inside the womb. Local anesthesia is usually applied to the cervix to decrease the pain of dilating the cervix. Local anesthesia numbs only the area injected and you remain conscious. Medication given intravenously (into a vein) can lessen anxiety and the body's general response to pain. Menstrual aspiration lasts about 15 minutes or less.

• Suction or aspiration abortion. Sometimes called a suction D & C (for dilation and curettage), this procedure can be done up to 13 weeks after the first day of the last menstrual period. Suction D & C is the procedure most commonly used to end a pregnancy. The cervix is dilated (widened) and a rigid hollow tube is inserted into the uterus. An electric pump sucks out the contents of the uterus. The process takes about 15 minutes. Local anesthesia is usually applied to the cervix to minimize the pain of dilating the cervix. Medication given intravenously (into a vein) may help to decrease anxiety and relieve pain.

• Dilation and curettage (D and C). In a dilation and curettage, the cervix is dilated and instruments with sharp edges, known as curettes, are used to remove the pregnancy tissue. Suction is often used to make sure all the contents of the uterus are removed. The earlier in pregnancy this procedure is done, the less the cervix has to be dilated, which makes the procedure easier and safer.

• Dilation and evacuation (D and E). This is the most common procedure for ending a pregnancy between 14 and 21 weeks. It is similar to a suction D and C but with larger instruments. The cervix has to be dilated or stretched open to a size larger than required for a D and C. Suction is used along with forceps or other special instruments to ensure all the pregnancy tissue is removed. The procedure takes more time than other abortion procedures.

• Abdominal hysterotomy. This is a major operation to remove the fetus from the uterus through an incision in the abdomen. This is rare but may be necessary if a D and E cannot be done. Anesthesia will make you unconscious for this surgery.

Induction of labor
After 14 weeks of pregnancy, abortion can be done by giving medication that causes the woman to go into labor and deliver the fetus and the placenta. The procedure usually requires hospitalization for more than a day because it involves a labor and delivery. Sometimes dilation and evacuation is necessary to completely remove the placenta. Labor can be induced in one of three ways:

• Invasive. Injecting labor inducing medications by passing a needle through the abdomen and into the uterus, usually within the amniotic sac
• Noninvasive. Giving labor inducing medications by mouth, intravenously (into a vein), through an injection into a muscle, or inserted in the vagina
• A combination of invasive and noninvasive approaches. Usually necessary when abortion is done late in the second trimester, before 24 weeks

Follow-Up

A medical abortion of an early pregnancy usually requires three or more visits to get abortion medication and make sure all the pregnancy tissue has passed. Bleeding related to the abortion may last up to two weeks.

You usually can resume most daily activities within hours after a surgical abortion that uses local anesthesia between 9 and 14 weeks, as long as no sedatives were used. If you received sedatives or were unconscious, as with general anesthesia, don't drive or use dangerous machinery for at least 24 hours. In either case, avoid sexual activity for 2 weeks to prevent infection and to allow the cervix and uterus to return to normal shape and size. Most women are advised to follow up at the doctor's office about 2 weeks after the procedure.

You usually can resume most daily activities a few days to a couple of weeks after a late second trimester abortion, depending on how far along you were in your pregnancy and whether there were complications. You may need to avoid sexual activity for two to six weeks after the procedure. In general, you should visit your doctor about two weeks after the procedure. Your doctor will give you specific advice about resuming daily activities and working based on your circumstances.

Cramps can be treated with acetaminophen (Tylenol) or ibuprofen (Advil and others). Cramping may be worse after a late second trimester abortion. After a medical or surgical abortion, you may be told not to use tampons or douches or have sex for at least two weeks. This will help to decrease the risk of an infection of the uterus. Vaginal spotting or bleeding is common for a few days up to one to two weeks after a surgical abortion, depending on how far along the pregnancy was at the time of the abortion.

Risks

The risks of a medical abortion include infection, bleeding and incomplete abortion, meaning some of the pregnancy tissue remains. These problems are rare and can be treated. An incomplete abortion is handled by repeating the dose of medication to end the pregnancy or doing a suction D and C. An infection can be treated with antibiotics. Excessive bleeding is treated with medications and possibly dilation and curettage. Rarely, a blood transfusion may be necessary if bleeding is unusually heavy.

The risks of a surgical abortion are quite low. The main risks of D and C and D and E are continued bleeding, infection of the uterus (endometritis), incomplete removal of pregnancy tissue and poking a hole in the womb (perforation of the uterus) during the surgical procedure. A second surgical procedure may be required to remove tissue that was not removed during the first procedure or to repair a perforated uterus.

Women rarely become infertile after an uncomplicated abortion. However, infertility may result when surgical abortion leads to endometritis or is complicated by heavy bleeding, perforation or incomplete removal of pregnancy tissue.

When to Call a Professional

Contact your doctor for any of the following problems:

• A fever of 100.4 degrees Fahrenheit or higher
• Bleeding heavier than a normal menstrual period, soaking pads at a rate of one per hour or more, or passing large clots
• Severe abdominal or back pain
• Unusual or foul smelling vaginal discharge
• No bleeding within 24 hours after the medical abortion of an early pregnancy

Additional Info

American College of Obstetricians and Gynecologists
P.O. Box 96920
Washington, DC 20090-6920
Phone: 202-638-5577
http://www.acog.org/

American Medical Women's Association (AMWA)
100 North 20th St.
4th Floor
Philadelphia, PA 19103
Phone: 215-320-3716
Fax: 215-564-2175
http://www.amwa-doc.org/

Planned Parenthood Federation of America
434 W. 33rd St.
New York, New York 10001
Phone: 212-541-7800
Toll-Free: 800-230-7526
Fax: 212-245-1845http://www.plannedparenthood.org/

American College of Nurse Midwives
8403 Colesville Road
Suite 1550
Silver Springs, MD 20910
Phone: 240-485-1800
Fax: 240-485-1818
http://www.midwife.org/

Association of Reproductive Health Professionals
1901 L Street, NW
Suite 300
Washington, DC 20036
Phone: 202-466-3825
Fax: 202-466-3826
http://www.arhp.org/

Alan Guttmacher Institute
125 Maiden Lane
7th Floor
New York, N.Y. 10038
Phone: 212-248-1111
Toll Free: 800-355-0244
Fax: 212-248-1951
http://www.agi-usa.org/

Population Council
Headquarters
One Dag Hammarskjold Plaza
New York, New York 10017
Phone: 212-339-0500
Fax: 212-755-6052
http://www.popcouncil.org/

National Women's Health Network
1413 K Street, NW
4th Floor
Washington, DC 20005
Phone: 202-682-2646
http://www.nwhn.org/