Abortion, Therapeutic

Definition

Therapeutic abortion is the intentional termination of a pregnancy before the fetus can live independently. Abortion has been a legal procedure in the United States since 1973.

Purpose

An abortion may be performed whenever there is some compelling reason to end a pregnancy. Women have abortions because continuing the pregnancy would cause them hardship, endanger their life or health, or because prenatal testing has shown that the fetus will be born with severe abnormalities.

Abortions are safest when performed within the first six to 10 weeks after the last menstrual period. The calculation of this date is referred to as the gestational age and is used in determining the stage of pregnancy. For example, a woman who is two weeks late having her period is said to be six weeks pregnant, because it is six weeks since she last menstruated.

About 90% of women who have abortions do so before 13 weeks and experience few complications. Abortions performed between 13-24 weeks have a higher rate of complications. Abortions after 24 weeks are extremely rare and are usually limited to situations where the life of the mother is in danger.

Precautions

Most women are able to have abortions at clinics or outpatient facilities if the procedure is performed early in pregnancy. Women who have stable diabetes, controlled epilepsy, mild to moderate high blood pressure, or who are HIV positive can often have abortions as outpatients if precautions are taken. Women with heart disease, previous endocarditis, asthma, lupus erythematosus, uterine fibroid tumors, blood clotting disorders, poorly controlled epilepsy, or some psychological disorders usually need to be hospitalized in order to receive special monitoring and medications during the procedure.

Description

Very early abortions

Between five and seven weeks, a pregnancy can be ended by a procedure called menstrual extraction. This procedure is also sometimes called menstrual regulation, mini-suction, or preemptive abortion. The contents of the uterus are suctioned out through a thin (3-4 mm) plastic tube that is inserted through the undilated cervix. Suction is applied either by a bulb syringe or a small pump.

Another method is called the "morning after" pill, or emergency contraception. Basically, it involves taking high doses of birth control pills within 24 to 48 hours of having unprotected sex. The high doses of hormones causes the uterine lining to change so that it will not support a pregnancy. Thus, if the egg has been fertilized, it is simply expelled from the body.

There are two types of emergency contraception. One type is identical to ordinary birth control pills, and uses the hormones estrogen and progestin). This type is available with a prescription under the brand name Preven. But women can even use their regular birth control pills for emergency contraception, after they check with their doctor about the proper dose. About half of women who use birth control pills for emergency contraception get nauseated and 20 percent vomit. This method cuts the risk of pregnancy 75 percent.

The other type of morning-after pill contains only one hormone: progestin, and is available under the brand name Plan B. It is more effective than the first type with a lower risk of nausea and vomiting. It reduces the risk of pregnancy 89 percent.

Women should check with their physicians regarding the proper dose of pills to take, as it depends on the brand of birth control pill. Not all birth control pills will work for emergency contraception.

Menstrual extractions are safe, but because the amount of fetal material is so small at this stage of development, it is easy to miss. This results in an incomplete abortion that means the pregnancy continues.

First trimester abortions

The first trimester of pregnancy includes the first 13 weeks after the last menstrual period. In the United States, about 90% of abortions are performed during this period. It is the safest time in which to have an abortion, and the time in which women have the most choice of how the procedure is performed.

KEY TERMS

Endocarditis— An infection of the inner membrane lining of the heart.

Fibroid tumors— Fibroid tumors are non-cancerous (benign) growths in the uterus. They occur in 30-40% of women over age 40, and do not need to be removed unless they are causing symptoms that interfere with a woman's normal activities.

Lupus erythematosus— A chronic inflammatory disease in which inappropriate immune system reactions cause abnormalities in the blood vessels and connective tissue.

Prostaglandin— Oxygenated unsaturated cyclic fatty acids responsible for various hormonal reactions such as muscle contraction.

Rh negative— Lacking the Rh factor, genetically determined antigens in red blood cells that produce immune responses. If an Rh negative woman is pregnant with an Rh positive fetus, her body will produce antibodies against the fetus's blood, causing a disease known as Rh disease. Sensitization to the disease occurs when the women's blood is exposed to the fetus's blood. Rh immune globulin (RhoGAM) is a vaccine that must be given to a woman after an abortion, miscarriage, or prenatal tests in order to prevent sensitization to Rh disease.

MEDICAL ABORTIONS. Medical abortions are brought about by taking medications that end the pregnancy. The advantages of a first trimester medical abortion are:

• The procedure is non-invasive; no surgical instruments are used.
• Anesthesia is not required.
• Drugs are administered either orally or by injection.
• The procedure resembles a natural miscarriage.

Disadvantages of a medical abortion are:

• The effectiveness decreases after the seventh week.
• The procedure may require multiple visits to the doctor.
• Bleeding after the abortion lasts longer than after a surgical abortion.
• The woman may see the contents of her womb as it is expelled.

Two different medications can be used to bring about an abortion. Methotrexate (Rheumatrex) works by stopping fetal cells from dividing which causes the fetus to die.

On the first visit to the doctor, the woman receives an injection of methotrexate. On the second visit, about a week later, she is given misoprostol (Cytotec), an oxygenated unsaturated cyclic fatty acid responsible for various hormonal reactions such as muscle contraction (prostaglandin), that stimulates contractions of the uterus. Within two weeks, the woman will expel the contents of her uterus, ending the pregnancy. A follow-up visit to the doctor is necessary to assure that the abortion is complete.

With this procedure, a woman will feel cramping and may feel nauseated from the misoprostol. This combination of drugs is 90-96% effective in ending pregnancy.

Mifepristone (RU-486), which goes by the brand name Mifeprex, works by blocking the action of progesterone, a hormone needed for pregnancy to continue, then stimulates ulerine contractions thus ending the pregnancy. It can be taken as much as 49 days after the first day of a woman's last period. On the first visit to the doctor, a woman takes a mifepristone pill. Two days later she returns and, if the miscarriage has not occurred, takes two misoprostol pills, which causes the uterus to contract. Five percent of women won't need to take misoprostol. After an observation period, she returns home.

Within four days, 90% of women have expelled the contents of their uterus and completed the abortion. Within 14 days, 95-97% of women have completed the abortion. A third follow-up visit to the doctor is necessary to confirm through observation or ultrasound that the procedure is complete. In the event that it is not, a surgical abortion is performed. Studies show that 4.5 to 8 percent of women need surgery or a blood transfusion after taking mifepristone, and the pregnancy persists in about 1 percent of women. In this case, surgical abortion is recommended because the fetus may be damanged. Side effects include nausea, vaginal bleeding and heavy cramping. The bleeding is typically heavier than a normal period and may last up to 16 days.

Mifepristone is not recommended for women with ectopic pregnancy, an IUD, who have been taking long-term steroidal therapy, have bleeding abnormalities or on blood-thinners such as Coumadin.

Surgical abortions

First trimester surgical abortions are performed using vacuum aspiration. The procedure is also called dilation and evacuation (D & E), suction dilation, vacuum curettage, or suction curettage.

Advantages of a vacuum aspiration abortion are:

• It is usually done as a one-day outpatient procedure.
• The procedure takes only 10-15 minutes.
• Bleeding after the abortion lasts five days or less.
• The woman does not see the products of her womb being removed.

Disadvantages include:

• The procedure is invasive; surgical instruments are used.
• Infection may occur.

During a vacuum aspiration, the woman's cervix is gradually dilated by expanding rods inserted into the cervical opening. Once dilated, a tube attached to a suction pump is inserted through the cervix and the contents of the uterus are suctioned out. The procedure is 97-99% effective. The amount of discomfort a woman feels varies considerably. Local anesthesia is often given to numb the cervix, but it does not mask uterine cramping. After a few hours of rest, the woman may return home.

Second trimester abortions

Although it is better to have an abortion during the first trimester, some second trimester abortions may be inevitable. The results of genetic testing are often not available until 16 weeks. In addition, women, especially teens, may not have recognized the pregnancy or come to terms with it emotionally soon enough to have a first trimester abortion. Teens make up the largest group having second trimester abortions.

Some second trimester abortions are performed as a D & E. The procedures are similar to those used in the first trimester, but a larger suction tube must be used because more material must be removed. This increases the amount of cervical dilation necessary and increases the risk of the procedure. Many physicians are reluctant to perform a D & E this late in pregnancy, and for some women is it not a medically safe option.

The alternative to a D & E in the second trimester is an abortion by induced labor. Induced labor may require an overnight stay in a hospital. The day before the procedure, the woman visits the doctor for tests, and to either have rods inserted in her cervix to help dilate it or to receive medication that will soften the cervix and speed up labor.

On the day of the abortion, drugs, usually prostaglandins to induce contractions, and a salt water solution, are injected into the uterus. Contractions begin, and within eight to 72 hours the woman delivers the fetus.

Side effects of this procedure include nausea, vomiting, and diarrhea from the prostaglandins, and pain from uterine cramps. Anesthesia of the sort used in childbirth can be given to mask the pain. Many women are able to go home a few hours after the procedure.

Very early abortions cost between $200-$400. Later abortions cost more. The cost increases about $100 per week between the thirteenth and sixteenth week. Second trimester abortions are much more costly because they often involve more risk, more services, anesthesia, and sometimes a hospital stay. Insurance carriers and HMOs may or may not cover the procedure. Federal law prohibits federal funds including Medicaid funds, from being used to pay for an elective abortion.

Preparation

The doctor must know accurately the stage of a woman's pregnancy before an abortion is performed. The doctor will ask the woman questions about her menstrual cycle and also do a physical examination to confirm the stage of pregnancy. This may be done at an office visit before the abortion or on the day of the abortion. Some states require a waiting period before an abortion can be performed. Others require parental or court consent for a child under age 18 to receive an abortion.

Despite the fact that almost half of all women in the United States have had at least one abortion by the time they reach age 45, abortion is surrounded by controversy. Women often find themselves in emotional turmoil when deciding if an abortion is a procedure they wish to undergo. Pre-abortion counseling is important in helping a woman resolve any questions she may have about having the procedure.

Aftercare

Regardless of the method used to perform the abortion, a woman will be observed for a period of time to make sure her blood pressure is stable and that bleeding is controlled. The doctor may prescribe antibiotics to reduce the chance of infection. Women who are Rh negative (lacking genetically determined antigens in their red blood cells that produce immune responses) should be given a human Rh immune globulin (RhoGAM) after the procedure unless the father of the fetus is also Rh negative. This prevents blood incompatibility complications in future pregnancies.

Bleeding will continue for about five days in a surgical abortion and longer in a medical abortion. To decrease the risk of infection, a woman should avoid intercourse and not use tampons and douches for two weeks after the abortion.

A follow-up visit is a necessary part of the woman's aftercare. Contraception will be offered to women who wish to avoid future pregnancies, because menstrual periods normally resume within a few weeks.

Risks

Serious complications resulting from abortions performed before 13 weeks are rare. Of the 90% of women who have abortions in this time period, 2.5% have minor complications that can be handled without hospitalization. Less than 0.5% have complications that require a hospital stay. The rate of complications increases as the pregnancy progresses.

Complications from abortions can include:

• uncontrolled bleeding
• infection
• blood clots accumulating in the uterus
• a tear in the cervix or uterus
• missed abortion where the pregnancy continues
• incomplete abortion where some material from the pregnancy remains in the uterus

Women who experience any of the following symptoms of post-abortion complications should call the clinic or doctor who performed the abortion immediately.

• severe pain
• fever over 100.4°F (38.2°C)
• heavy bleeding that soaks through more than one sanitary pad per hour
• foul-smelling discharge from the vagina
• continuing symptoms of pregnancy

Normal results

Usually the pregnancy is ended without complication and without altering future fertility.

Resources

BOOKS

Carlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn. "Abortion." In The Harvard Guide to Women's Health. Cambridge, MA: Harvard University Press, 1996.