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MoonDragon's ObGyn Information
ABORTION INFORMATION
OVERVIEW & INDEX
THERAPEUTIC ABORTION OVERVIEW & INFORMATION
Important... These pages are for informational purposes only and do not
replace important care given by your health care provider or midwife.
THERAPEUTIC ABORTION OVERVIEW
THERAPEUTIC ABORTION INTRODUCTION
Therapeutic abortion is defined as the termination of pregnancy before fetal viability in order to preserve maternal health. In its broadest definition, therapeutic abortion can be performed to:(1) Save the life of the mother.
(2) Preserve the health of the mother.
(3) Terminate a pregnancy that would result in the birth of a child with defects incompatible with life or associated with significant morbidity.
(4) Terminate a non-viable pregnancy.
(5) Selectively reduce a multi-fetal pregnancy.
The vast majority of abortions performed in the United States are elective. Pregnancy-related conditions that threaten maternal life are rare and difficult to define precisely. The decision to terminate a pregnancy for medical indications is generally a multi-disciplinary decision including the obstetrician, a specialist in the disease entity in question, the patient, and the patient's family.
The methods used to terminate pregnancy vary according to gestational age, the indication for termination, and medical and surgical considerations relevant to the mother. Abortion can be accomplished by surgical or medical means.
ABORTION PROCEDURE HISTORY
Termination of pregnancy has been practiced since ancient times and by all cultures. The indications and social context for termination of pregnancy vary with culture and time. The use of abortion to preserve the life of the mother has been widely accepted. Early Jewish scholars' interpretation of the Talmud required that the fetus be destroyed if it posed a threat to the mother during delivery. The ancient Greeks allowed abortion under certain circumstances. Ancient Romans did not consider a fetus a person until after birth, and abortion was practiced widely. Early Christians had varying practices regarding abortion. By 1869, the Catholic church declared abortion a sin punishable by excommunication.
In the United States, legislation regarding abortion has varied with the times. Before 1800, no statutes addressed the subject of abortion. The first anti-abortion legislation appeared in the 1820s; the preservation of pregnant women's health was the motivating force. During this time, the mortality rate from abortion was high, while the mortality rate from childbirth was less than 3 percent. By 1900, abortion in the United States at any time during pregnancy was a crime, with the exception of therapeutic abortion performed to save the mother's life.
During the 1950s, the practice of medicine came under increasing scrutiny, and guidelines were set to define the indications for therapeutic abortion. The guidelines allowed therapeutic abortion if:(1) Pregnancy would "gravely impair the physical and mental health of the mother."
(2) The child born was likely to have "grave physical and mental defects."
(3) The pregnancy was the result of rape or incest.
In the United States, the legalization of abortion by Roe versus Wade in 1973 upheld the fundamental right of a woman to determine whether to continue her pregnancy.
PREGNANCY PROBLEMS & THERAPEUTIC ABORTION
US statistics indicate that the vast majority of abortions are elective. Therapeutic abortion is rare. The ability to define therapeutic abortion performed for maternal indications is difficult because of the subjective nature of decisions made about potential morbidity and mortality in pregnant women. A variety of medical conditions in pregnant women have the potential to affect health and cause complications that may be life threatening.
Prenatal screening in the form of prenatal diagnostic testing continues to improve the antepartum diagnosis of fetal anomalies. The decision to continue or terminate a pregnancy complicated by fetal anomalies is a difficult decision. The most difficult decisions are associated with anomalies that are unpredictable or highly variable in their expression.
The increase in the use of assisted reproductive technologies has been associated with an enormous increase in multi-fetal pregnancies. Twins have increased in frequency from 1 set per 90 pregnancies to 1 set per 45 pregnancies. Higher-order multi-fetal pregnancies have quadrupled in the past 20 years. These pregnancies are complicated by increased fetal morbidity and mortality rates, which are largely caused by prematurity and growth retardation. Selective reduction has been introduced as a technology to improve perinatal outcomes in these pregnancies and has been successful in reducing preterm deliveries and associated perinatal morbidity and mortality.
ABORTION FREQUENCY & DETERMINING FACTORS
FREQUENCY OF THERAPEUTIC ABORTION
Approximately 3 to 5 percent of all newborns have a recognizable birth defect. The suggested causes of fetal anomalies are as follows:
- Genetic (ie, chromosomal) (20-25 percent)
- Fetal infections (3-5 percent)
- Maternal disease (4 percent).
- Drugs/medications (less than 1 percent).
- Unknown (65-70 percent).
Patients in need of therapeutic termination of pregnancy can be identified at any gestational age; however, the consideration of therapeutic abortion is generally limited to pregnancies at 24 weeks' gestation or less. Many patients are in the second trimester of pregnancy because of the timing of fetal assessment tools (eg, triple screen, amniocentesis, ultrasound).
The indications for therapeutic abortion, in its broadest definition, are as follows:
- To save the life of the pregnant woman.
- To preserve the health of the pregnant woman.
- To terminate a pregnancy that would result in the birth of a child with defects incompatible with life or associated with significant morbidity.
- To terminate a non-viable pregnancy (dead fetus).
- To selectively reduce a multi-fetal pregnancy.
Therapeutic abortions to save the life of the mother or to preserve the health of the mother are rare events. The decision should be based on the collaborative agreement of a multidisciplinary team. At minimum, the team should consist of the patient, the obstetrician, a specialist with knowledge of the disease in question, an expert in genetic counseling, and a neonatologist. Additional members may include spiritual counselors, nurses, psychologists/psychiatrists, intensive care specialists, ethicists, and family members.
The decision to terminate the pregnancy includes consideration of the effect of the pregnancy on disease outcome, the effect of treatment on fetal outcome, the gestational age of the pregnancy, the level of attachment of the patient to the pregnancy, the desires of the patient and the father, and the availability of family resources/support. This complex situation requires thought and excellent communication among the involved parties regarding the short- and long-term consequences of the decision to abort or continue the pregnancy. The decision must be individualized for each patient. There must be an inherent acceptance of the subjective nature of decisions made in this area. The clinical situations may be rare, and clinical data available may be anecdotal, incomplete, and/or inconclusive.
Commonly accepted medical indications for therapeutic termination of pregnancy include severe hypertensive vascular disease, cardiac disease with cardiac decompensation, and certain malignancies.
MEDICAL PROBLEMS & COMPLICATIONS
Medical complications during pregnancy encompass a wide array of medical problems, to include the following:
- Hypertensive (high blood pressure) disorders.
- Diabetes mellitus.
- Hematologic disorders.
- Cardiovascular diseases.
- Thromboembolic disorders.
- Thyroid and parathyroid diseases.
- Pituitary disorders.
- Adrenal disorders.
- Renal diseases.
- Hepatic diseases.
- GI tract disorders.
- Pulmonary diseases.
- Infectious diseases.
- Neurologic diseases.
- Psychiatric disorders.
- Malignancies.
The diseases tend to occur in frequencies compatible with those of non-pregnant age-matched women. Providing an in-depth review of this wide array of medical problems is beyond the scope of this discussion.
CANCER DURING PREGNANCY
The total incidence of malignancy during pregnancy is estimated at 1 case per 1000 pregnancies. The most common cancers found in pregnant women mirror those found in their non-pregnant counterparts, to include the following:
- Cervical cancer (1 case per 2200 pregnancies). Cervical cancer is the most common malignancy affecting pregnant women. Invasive cervical cancer is treated with surgery or radiation; both treatment modalities result in fetal death for the pre-viable fetus. Delay of therapy is the only option that allows fetal salvage in this setting. Treatment delays to allow fetal maturation have been successfully attempted in stages IA and IB. Treatment delays for advanced disease (stages IIB-IV) are controversial. All decisions regarding delay must be individualized and must consider other factors that affect the prognosis (eg, HIV status).
MoonDragon's ObGyn Information: Cervical Cancer
- Breast cancer (1 case per 3000 pregnancies). The prognosis for patients with breast cancer is not adversely affected by continuation of pregnancy. The decision to terminate a pregnancy complicated by breast cancer in the first and second trimesters is determined by the degree to which the pregnancy impairs effective treatment and whether treatment presents a risk to the fetus.
- Melanoma (0.14-2.8 cases per 1000 pregnancies). The prognosis for patients with melanoma is not improved by therapeutic abortion. Metastatic spread of melanoma to the placenta and fetus has been reported but is very rare. This type of spread has also been reported with lymphoma, leukemia, breast cancer, lung cancer, and stomach cancer and should be addressed when counseling at-risk patients.
OTHER MALIGNANCIES
- Ovarian cancer.
- Thyroid cancer.
- Leukemia (rare).
- Lymphoma.
- Colorectal carcinoma (0.10-1.0 cases per 1000 pregnancies).
FETAL CONDITIONS
A pregnancy in which the fetus has defects that are either incompatible with life or associated with significant morbidity can be an indication for therapeutic abortion. The number of fetal conditions that can be identified during pregnancy is always expanding because of improvements in technology available for antenatal diagnosis. The following fetal conditions are identifiable:
- Chromosomal disorders.
- X-linked disorders.
- Metabolic disorders.
- Neural tube defects.
- Structural anomalies associated with exposure to teratogens.
- Structural anomalies of multi-factorial or unknown etiology.
MULTI-FETAL PREGNANCIES
Multi-fetal pregnancies are associated with high fetal morbidity and mortality rates. In this setting, morbidity and mortality are associated with high rates of preterm delivery and growth retardation. Preterm birth rates at less than 33 weeks' gestation are 8 times higher for twins and 24 times higher for triplets compared with singleton pregnancies. Each additional fetus in a pregnancy reduces the length of the pregnancy by approximately 3.6 weeks. After birth, the mortality rates for infants born in multiple pregnancies remain elevated from birth to age 5 years, even after controlling for growth restriction.
Multi-fetal reduction has been shown to reduce the risk of preterm delivery for the remaining fetuses. However, the incidence of prematurity in reduced pregnancies appears to remain higher than in spontaneous pregnancies of the same fetal number. An overall reduction in morbidity-improved survival rates occurs in reduced pregnancies compared with pregnancies in which reduction is not performed.
RELEVANT ANATOMY
Adequate evaluation of uterine size is mandatory. Physical examination may be inadequate for uterine sizing because of the following factors:
- Obesity.
- Patient apprehension with voluntary guarding.
- Presence of a retroverted uterus.
- Firm abdominal musculature.
- Uterine leiomyoma (fibroid).
Obtaining ultrasound confirmation of gestational age is common practice when a therapeutic abortion is planned. Anticipating potential complications associated with the abortion procedure is important.
Consider anatomic problems that may contribute to technical difficulties during an abortion. Make every attempt to minimize complications because of their impact on a patient who may already be compromised because of an underlying disease. A small, stenotic, or scarred cervical os may impair the cervical dilation necessary for safe surgical terminations of pregnancy. A long vaginal canal may also make the use of surgical instruments difficult, and labor induction may need to be considered.
The presence of uterine leiomyomas (uterine fibroids) may make uterine sizing erroneous and the dilation of the cervix difficult or impossible and may contribute to increased blood loss at the time of either surgical or medical abortion procedures.
Abnormal placentation (ie, placenta previa, placenta accreta, placenta percreta) is associated with high parity and previous uterine surgery. This issue must be addressed carefully. Abnormal placentation requires surgical intervention with careful consideration of the anticipated amount of blood loss. The selected surgical abortion method should cause minimal blood loss and be of limited invasiveness. For certain patients, special interventions, such as embolization using interventional radiology techniques, may be needed on a standby basis.
The presence of uterine anomalies (e.g., uterus didelphys [double uterus], unicornuate uterus, septate uterus) may make entering and emptying of the uterus complicated. If surgical abortion is selected, ultrasound guidance during the procedure may be helpful. The abortion of a multiple gestation may make surgical abortions more challenging, and the use of ultrasound guidance is helpful. Data are not available for the use of medical abortion in this setting.
Careful consideration of the choice of anesthesia must be based on the medical, psychiatric, and emotional condition of the patient. Consultation with anesthetists, medical specialists, and psychiatric specialists may be necessary to determine the best choice of anesthesia for an individual patient. In general, local anesthesia affords the greatest safety. General anesthesia for surgical abortions is associated with greater overall risk of anesthesia complications and hemorrhage.
ABORTION CONTRAINDICATIONS
Absolute contraindications to termination of pregnancy are virtually unknown. In the face of significant maternal risk of medical or psychiatric morbidity/mortality, continuation of pregnancy usually presents far greater risk than termination of pregnancy. A particular type of abortion procedure or the timing of abortion may be contraindicated based on the current medical, surgical, or psychiatric condition of a patient. For example, medical abortion is contraindicated in patients with the following conditions:
- Clotting disorders.
- Severe liver diseases.
- Renal diseases.
- Severe cardiac diseases.
- Long-term steroid use.
- Medical conditions or use of medications that preclude the use of medical abortion medications.
- Adrenal failure.
- Undiagnosed adnexal masses.
- Ectopic pregnancy (except with use of methotrexate).
Medical abortion should be performed with caution in patients with the following conditions:
- Severe anemia.
- Poorly controlled bowel disease (may cause an exacerbation of symptoms).
Surgical abortion is contraindicated in patients with the following conditions:
- Hemodynamic instability.
- Profound anemia.
- Profound thrombocytopenia.
Instillation abortion techniques are contraindicated in patients with the following conditions:
- Active pelvic infections.
- Inability to tolerate a solute load (saline only).
- Asthma, glaucoma, epilepsy, hypertensive cardiovascular disease, pulmonary hypertension (prostaglandin F2 a [PGF2 a])
- Fetal demise (saline, urea).
The rare patient with placenta accreta or placenta percreta may require consideration of laparotomy with hysterotomy/hysterectomy despite the increased morbidity and mortality risks associated with these procedures.
Multi-fetal reduction of pregnancy has inherent risks of rupture of membranes, preterm labor, preterm delivery, and infection, which must be balanced against the benefits of the procedure. Special circumstances, such as the selection of the presenting fetus for reduction, may present a greater risk of loss of the entire pregnancy and must be considered in the risk-benefit analysis.
In patients with significant medical or surgical risk, the choice of abortion procedure must be individualized. All abortion methods may present relative or absolute contraindications for some patients. In the face of limited or absent data for a specific clinical situation, the choice of abortion method is based on the best collective medical judgment of the team of clinicians caring for the patient.
LABORATORY STUDIES
SURGICAL ABORTION
Pregnancy test, CBC count, and blood typing are the minimum laboratory studies required for surgical abortion.
- A pregnancy test is required to exclude non-pregnancy-related causes of secondary amenorrhea.
- A CBC count is required to identify patients with significant anemia, who are at risk if excessive blood loss occurs. Transfusion may be needed, particularly in second-trimester abortions. Patients with severe anemia are best treated in a setting where transfusion is available.
- Blood typing is required so that Rh-negative women can be identified and given RhoGAM to prevent Rh sensitization in subsequent pregnancies.
- Screening for common sexually transmitted diseases (STDs) should be addressed in geographic areas of high prevalence, in age groups at high risk (i.e,, maternal age less than 25 years), and in at-risk groups (e.g., those with histories of STDs, multiple sex partners, substance abuse).
- Additional laboratory testing is dictated by the medical history and physical examination findings.
- Coagulation studies are indicated for patients with conditions such as a history of coagulopathy, hematologic malignancies, hemorrhage with previous surgical procedures, petechiae, bruising, and hepatosplenomegaly.
- Liver function tests are indicated for patients with conditions such as hepatitis, alcohol abuse, metastatic cancer, hepatomegaly, and jaundice.
- Renal function tests are indicated for patients with conditions such as renal disease, recurrent urinary tract infections, oliguria, hematuria, and proteinuria.
MEDICAL ABORTION
Pregnancy test, CBC count, and blood typing are the minimum laboratory studies required for medical abortion.
- In cases of methotrexate use, platelet count, electrolytes, liver function tests, and BUN and creatinine levels are required. Thrombocytopenia and chemical hepatitis are rare (in the doses used for medical abortion) but known complications of methotrexate use.
- Electrolyte assays are necessary in patients who develop significant vomiting associated with the use of medical abortion techniques.
- See Surgical Abortion (above) for other laboratory studies and indications for their use.
INSTILLATION TECHNIQUES
A pregnancy test and CBC count are required; see Surgical Abortion for indications.
- Platelets, coagulation studies, liver function tests, and renal function tests are recommended as baseline testing for instillation methods because of the risk of coagulopathy, vomiting, and diarrhea associated with this method.
SELECTIVE REDUCTION
No specific laboratory tests are required; however, specific laboratory tests may be ordered for individual patients based on history and physical examination findings.
IMAGING STUDIES
Baseline ultrasounds are routinely used in medical abortion, surgical abortion, and instillation abortion techniques.
A chest radiograph may be indicated depending on history and physical examination findings.
OTHER DIAGNOSTIC TESTS & PROCEDURES
Chorionic villus sampling or amniocentesis for fetal chromosome evaluation may be indicated depending on maternal age, obstetric history, family history, or ultrasound findings.
Specialized testing is needed for certain indications. For example, fetal umbilical cord blood sampling is indicated when fetal blood must be obtained for diagnostic testing.
An ECG may be indicated depending on maternal age, history, physical examination findings, and anesthesia requirements.
Autopsy should be considered for all second trimester anomalies. The combination of genetic sampling (either by amniocentesis or cytogenetic specimen from the fetus and placenta) and autopsy should be offered to these patients to provide as much diagnostic information for the patient to facilitate counseling for future pregnancies.
HISTOLOGIC FINDINGS
Collecting tissue for pathologic examination is generally impossible for first-trimester medical abortion and is not part of the recommended protocol. Collection of tissue for pathologic examination for surgical abortion and second-trimester medical abortion is routine.
The obligation to collect tissue from abortion procedures is determined by state abortion regulations and must be addressed in a state-by-state manner. The need to collect tissue for diagnosis of fetal anomalies is addressed on a case-by-case basis. The same state and federal statutes apply for medical and surgical abortions despite the fact that the laws were written for surgical abortion.
TREATMENT
MEDICAL ABORTION THERAPY
Medical therapy includes instillation techniques and medical abortion techniques.
INSTALLATION TECHNIQUES
Instillation agents include hypertonic saline, hypertonic urea, and prostaglandin. All instillation agents function by inducing uterine contractions, which end in the evacuation of the uterine contents. The instillation technique is performed in a similar fashion for all agents. Selected patients are in the second trimester of pregnancy. The patient empties her bladder, and the abdomen is cleansed with an antiseptic solution. An amniotic fluid pocket can be identified using ultrasound. Alternatively, the skin can be anesthetized using a local anesthetic. An 18-gauge spinal needle is transabdominally introduced into the amniotic sac. Free flow of amniotic fluid is confirmed. (Fluid can be tested with pH paper; urine is acidic, amniotic fluid is basic.) The abortifacient is injected, as follows:
- Hypertonic saline: Inject 40 g (ie, 200 mL 20 percent saline).
- Hypertonic urea: Inject 80 g in 5 percent D5W.
- PGF2a: Inject 20-40 mg. Use a test dose of 2.5-5 mg, followed by 17.5-35 mg.
In instillation techniques, the cervix is made inducible by the use of passive dilators (laminaria, Dilapan inserted in cervix) or use of intravaginal prostaglandins (eg, misoprostol, prostaglandin E2 [PGE2] suppositories).
MEDICAL ABORTION TECHNIQUES
Medical abortion agents include:1. Mifepristone and misoprostol.
2. Methotrexate and misoprostol.
3. Misoprostol.
Mifepristone is a progesterone antagonist that blocks the effects of progesterone by competing with endogenous progesterone for receptor binding. The primary effect is on the uterus, where it blocks the effect of progesterone on the endometrium and decidua. The endometrium degenerates and is shed, disrupting the implanted embryo/fetus. The endometrial lining and its contents are expelled. The normal suppression of uterine activity induced in the pregnant uterus by progesterone is lost. The cervix is dilated and softened by poorly understood mechanisms.
Methotrexate is a folic acid antagonist that works by inhibiting dihydrofolate reductase, an enzyme needed to make DNA. In its role as an antimetabolite, methotrexate is toxic to the rapidly dividing cells of the trophoblast.
Misoprostol is a prostaglandin analog that acts by causing uterine contractions, which evacuate the uterine contents.
MIFEPRISTONE & MISOPROSTOL MEDICAL ABORTION
Medical abortion using mifepristone and misoprostol at up to 49 days' gestation has been approved by the US Food and Drug Administration (FDA). Patients must meet the following criteria:
- Forty-nine days or less from last menstrual period.
- No contraindications for an outpatient procedure.
- Capability and willingness to follow the procedures and instructions associated with medical abortion.
- Willingness to consent to surgical abortion if medical abortion fails.
- No contraindications for the medications used for medical abortion.
The procedure requires 3 visits, as follows:
- DAY 1
- Counseling is performed, and consent is obtained.
- History is obtained, and physical examination is performed.
- Pregnancy is dated by dates, sizing, and ultrasound.
- Hemoglobin and blood type are checked.
- Mifepristone 600 mg is given orally. (If the patient vomits 15 min or more after administration, absorption is probably adequate.)
- DAY 3
- RhoGAM is administered if needed.
- Misoprostol 400 mcg is given orally.
- Patients are monitored for 4 hours. (50-75 percent abort within 4 hours of misoprostol administration.)
- Give Tylenol, Tylenol with codeine, or a nonsteroidal anti-inflammatory drug (NSAID) for pain relief. Avoid aspirin and other medications with anticoagulant properties.
- DAY 15
- Assess completion of abortion by physical examination and ultrasound.
- Review aftercare measures and contraception.
The following variations on this protocol have been reported in the literature, with low occurrence of adverse effects, good patient acceptance, and comparable effectiveness:
- Use up to 56 days.
- Self-administration of misoprostol 800 mcg per vagina on day 3 at home.
- Repeated dose of misoprostol on day 7 if needed.
METHOTREXATE & MISOPROSTOL MEDICAL ABORTION
Patients must meet the following criteria:
- Forty-nine days or less from last menstrual period.
- No contraindications for an outpatient procedure.
- Capability and willingness to follow the procedures and instructions associated with medical abortion.
- Willingness to consent to surgical abortion if medical abortion fails.
- No contraindications for the medications used for medical abortion.
Patients may be up to 63 days from their last menstrual period. The procedure requires a minimum of 3 visits, as follows:
- DAY 1
- Counseling is performed, and consent is obtained.
- History is obtained, and physical examination is performed.
- Pregnancy is dated by dates, sizing, and ultrasound.
- Hemoglobin and blood type are checked.
- Administer methotrexate 50 mg/m2 intramuscularly instead of mifepristone.
- DAYS 3-5: RhoGAM is administered if needed.
- DAYS 5-7
- Misoprostol 800 mcg per vagina is self-administered at home.
- Alternatively, repeat misoprostol in 24 hours if no vaginal bleeding occurs.
- DAY 8: Assess for completion of abortion using ultrasound.
- If ultrasound reveals an incomplete abortion, repeat misoprostol.
- If fetal cardiac activity is present, follow up on day 15.
- If fetal cardiac activity is absent, follow up on day 36.
- DAY 15: Assess for completion of abortion using ultrasound.
- If ultrasound reveals an incomplete abortion, repeat misoprostol.
- If fetal cardiac activity is present, obtain a surgical abortion.
- DAYS 29-45: Assess for completion of abortion using ultrasound.
- If a gestational sac is still observed, obtain a surgical abortion.
- If fetal cardiac activity is absent, follow up on day 36.
MISOPROSTOL
For medical abortion in the second trimester (17-24 weeks), passive dilators (laminaria, Dilateria, Foley balloon) are inserted into the cervix. A 200-mcg misoprostol tablet is placed in the posterior vaginal fornix, followed by gauze sponges. The misoprostol dose is repeated in 12 hours, and the passive dilators and sponges are removed. Higher dose regimens can also be used. One such regimen is to use 400 mcg of misoprostol followed by 800 mcg 6 hours later, and then every 12 hours. Alternatively, 400 mcg every 6 hours can also be used.
Patients are medicated with promethazine, acetaminophen, diphenoxylate, intravenous/ intramuscular analgesics as needed for pain, fever, nausea, and diarrhea. If the fetus does not deliver in 24 hours, add a 20-mg dinoprostone intravaginal suppository every 3 hours until delivery of the fetus occurs. Add intravenous oxytocin 20-30 U/L of Ringer lactate solution to run at 150 mL/hour after delivery of the fetus.
All patients should be counseled and consented for dilation and curettage in the event of a retained placenta.
SELECTIVE REDUCTION
The techniques available for selective reduction include the following:
- Intracardiac injection (potassium chloride or digoxin).
- Cord occlusion techniques:
- Embolization with alcohol, enbucrilate gel.
- Nd:YAG laser photocoagulation.
- Fetoscope cord ligation.
- Bipolar cord coagulation.
- Monopolar cord coagulation.
MEDICATIONS
Medication-Drug Category: Abortifacient agents (Used to produce abortions).
Adult Dose: Inject 40 grams (200 mL) transabdominally into amniotic sac.
Pediatric Dose: Not established
Contraindications: Increased intra-amniotic pressure, blood disorders (ie, coagulation factor deficiencies, thrombocytopenia, fibrinolytic defects).
Interactions: Terbutaline may antagonize effect on uterine activity; indomethacin may increase time from induction to abortion.
Pregnancy: C-Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus.
Precautions: Caution in patients with cardiac disease, hypertension, epilepsy, serious renal impairment, or pelvic adhesions.
Adult Dose: Inject 80 grams (40-50 percent solution in D5W) transabdominally into amniotic sac.
Pediatric Dose: Not established.
Contraindications: Documented hypersensitivity; severe renal impairment; frank liver disease; intracranial bleeding; sickle cell anemia.
Interactions: Aspirin may increase time from induction to abortion.
Pregnancy: C-Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus.
Precautions: Monitor for fluid and electrolyte imbalances.
Adult Dose: Inject 20-40 mg transabdominally into amniotic sac.
Pediatric Dose: Not established.
Contraindications: Documented hypersensitivity; acute pelvic inflammatory disease; wanted pregnancy.
Interactions: Increased effect or toxicity of oxytocic agent.
Pregnancy: X-Contraindicated; benefit does not outweigh risk.
Precautions: Caution in patients with anemia, asthma, diabetes mellitus, epilepsy, compromised uterus (i.e., fibroid tumors, surgery), cardiovascular disease, hypertension or hypotension, renal or hepatic impairment; associated with GI distress, flushing, headache, arrhythmias, angina, uterine rupture, dyspnea, wheezing, blurred vision.
Adult Dose: Less than 49 days since LMP: 600 mg mifepristone PO as single dose, follow in 48 hours with 400 mcg misoprostol PO.
Alternative: 600 mg mifepristone PO as single dose, follow in 48 hours with 800 mcg misoprostol PO; may repeat misoprostol on day 7 prn; regimen may be effective up to 56 days since LMP.
Pediatric Dose: Not established.
Contraindications: Documented hypersensitivity; anticoagulant therapy; bleeding disorders; contraceptive devices (IUDs); ectopic pregnancy; adrenal insufficiency.
Interactions: Decreases effect of corticosteroids; increases levels of warfarin, alfentanil, benzodiazepine (i.e., alprazolam, triazolam, midazolam); antiretroviral protease inhibitors; calcium channel blockers (i.e,, nifedipine, diltiazem, verapamil); carbamazepine; cilostazol; cyclosporine; fentanyl; atorvastatin, lovastatin, simvastatin, cerivastatin (removed from US market 8/8/01); quinidine; quinine; sertraline; adverse cardiac effects, cisapride, dofetilide, pimozide.
Pregnancy: X-Contraindicated; benefit does not outweigh risk.
Precautions: Caution in patients with cardiovascular disease, pulmonary disease (i.e., asthma, COPD), diabetes mellitus, renal or hepatic impairment.
Adult Dose: 50 mg/m2 IM or 50 mg PO, followed by 800 mcg misoprostol PV 5-7 days later, may repeat misoprostol in 24 hours if no vaginal bleeding occurs.
Pediatric Dose: Not established.
Contraindications: Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (e.g., bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency.
Interactions: Oral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response; coadministration with NSAIDs may be fatal; indomethacin and phenylbutazone can increase plasma levels; may decrease phenytoin serum levels; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity; may increase plasma levels of thiopurines.
Pregnancy: X-Contraindicated; benefit does not outweigh risk.
Precautions: Has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested).
Adult Dose: During second trimester (17-24 weeks): 200-mcg tab placed in posterior vaginal fornix, repeat in 12 hours; if fetus not delivered in 24 hours, add 20-mg dinoprostone intravaginal suppository q3h until delivery of fetus.
With mifepristone: 400 mcg PO 48 hours after mifepristone.
With methotrexate: 800 mcg PV 5-7 days after methotrexate, if no vaginal bleeding repeat in 24 hours.
Pediatric Dose: Not established.
Contraindications: Documented hypersensitivity.
Interactions: None reported.
Pregnancy: X-Contraindicated; benefit does not outweigh risk.
Precautions: Caution in patients with renal impairment and in elderly patients.
Adult Dose: Medical abortion: 20 mg PV q3h until delivery of fetus occurs.
Pediatric Dose: Not established.
Contraindications: Documented hypersensitivity; acute pelvic inflammatory disease; uterine fibroids; cervical stenosis.
Interactions: Increased effects of oxytocics.
Pregnancy: C-Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus.
Precautions: Caution in patients with anemia, asthma, cervicitis, infected endocervical lesions, acute vaginitis, diabetes mellitus, epilepsy, compromised uteri (ie, fibroid tumors, surgery), cardiovascular disease, hypertension or hypotension, renal or hepatic impairment; associated with GI distress, headache, arrhythmias, angina, uterine rupture, dyspnea, wheezing.
SURGICAL ABORTION THERAPY
Surgical abortion techniques available for therapeutic termination of pregnancy include the following:
- Manual vacuum aspiration (ie, menstrual extraction).
- Suction curettage.
- Dilation and extraction.
- Hysterotomy.
- Hysterectomy.
The choice of surgical abortion technique depends on the gestational age of the pregnancy; the expertise of the available medical staff; the clinical importance of obtaining an intact fetus; and the medical, surgical, psychiatric, and anesthetic contraindications to the various techniques.
PREOPERATIVE DETAILS
For selective reduction procedures, evaluation of the fetuses using chorionic villus sampling or amniocentesis can assist in selection of the appropriate fetuses for reduction.
The use of ultrasound to assess fetal growth, fetal heart rate, and fetal nuchal thickening can also be helpful in the selection process. Criteria such as nuchal translucency of more than 3 mm, a lag in growth longer than 3 days, or a heart rate less than 80 beats per minute can be used to select the appropriate fetus for reduction.
FOLLOW-UP
For patient education resources, discuss with your health care provider. Also, see MoonDragon's articles Abortion Methods, Miscarriage, and Dilation and Curettage (D&C) - links below under Abortion Index
COMPLICATIONS
As with all interventions, complications are associated with all methods used for termination of pregnancy.
SURGICAL ABORTION COMPLICATIONS
Complications of surgical abortion vary with the technique used 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 percent for hospitalization and 0.846 percent for minor complications. Abortion complications requiring hospitalization include incomplete abortion (0.028 percent), sepsis (0.021 percent), uterine perforation (0.009 percent), vaginal bleeding (0.007 percent), inability to abort (0.003 percent), and combined pregnancy (0.002 percent). Minor abortion complications include infection (0.46 percent), repeat suction (0.18 percent), cervical stenosis (0.016 percent), cervical tear (0.01 percent), seizure (0.004 percent), and underestimate of dates (0.006 percent).
Manual Vacuum Aspiration has the following complication rates: infection, 0.7 percent; perforation, 0.05 percent; retained POC, 0.5 percent; and repeat aspiration, 0.5-0.25 percent.
Second-Trimester Abortion: In D&E and D&X, the skill and experience of the practitioner 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 percent at 13 weeks of gestation and 1.4 percent 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 previa (or other abnormal placentation), pelvic masses or large leiomyomas, or vein problems (e.g., no intravenous access). Choose to delay the operative procedure in patients with acute infection, severe vaginitis, or uncertain pregnancy dating.
Choose hysterotomy/hysterectomy as a last resort because these procedures have the highest morbidity and mortality rates of all abortion methods.
Damage To Cervix: Risk 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.
Hemorrhage: Hemorrhage can be caused by atony, retained products, or perforation. General anesthesia increases the risk of atony. Blood loss of more than 300 mL in the first trimester is considered excessive. Treatment includes uterine massage, Pitocin (40 units in 1 L crystalloid) or intramuscular/ intracervical Methergine (methylergonovine maleate) or intramuscular Hemabate (15-methyl prostaglandin), removal of retained products, and repair of perforation as indicated. In cases where hemorrhage cannot be adequately controlled despite the above measures, pelvic embolization, if available, may be effective. If ineffective, hysterectomy should be performed as a life-saving measure.
Prevent hemorrhage by ensuring complete evacuation of the uterus, avoiding use of general anesthesia, and obtaining adequate cervical dilation. In conditions in which hemorrhage is anticipated (such as known placenta accreta), preoperative placement of catheters, prophylactic pelvic embolization, or readiness to place catheters are options that should be considered in an effort to minimize the need for emergent hysterectomy.
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 re-aspiration.
Infection: Fever greater than 102°F (39°C) within 72 hours of the abortion should be considered septic abortion due to retained products. Treatment requires re-aspiration 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 re-aspiration and oral antibiotics (doxycycline 100 mg bid for 10 days).
Perforation: 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 ultrasound 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.
Mortality From Abortion: 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 longer 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 longer than 21 weeks of gestation.
Anesthesia Risks: The use of local anesthesia is favored over general anesthesia because the latter poses a greater risk of maternal complications. Allergic reactions to local anesthetic can be treated by intravenous epinephrine or intramuscular diphenhydramine. Significant complications from local anesthesia are most often due to toxic levels of the anesthetic resulting in convulsions and cardiopulmonary arrest. To avoid exceeding toxic dose levels, do not administer more than 20 mL of 1 percent lidocaine, or the equivalent, for a paracervical block. Treatment of cardiopulmonary arrest consists of cardiopulmonary resuscitation and basic life support. MEDICAL ABORTION COMPLICATIONS
Medical abortions in the first trimester are safe and well-tolerated procedures. The major problems are decreased effectiveness of medical abortion with increasing gestational age and the long interval between administration of medication to completion of abortion for certain medications (e.g., methotrexate, tamoxifen).
Complications and adverse effects associated with specific medications are as follows:
- Methotrexate & Misoprostol: Complications associated with the proper dose are rare, but the following can occur:
- Stomatitis (0.66 percent).
- GI morbidity.
- Nausea (10-37 percent).
- Vomiting (7-25 percent).
- Diarrhea (2-52 percent).
- Thrombocytopenia.
- Chemical hepatitis.
- Failed abortion (4-12 percent).
- Mifepristone & Misoprostol:
- Transfusion (0.1 percent).
- Pain requiring narcotic analgesia (4-15 percent).
- Vomiting (12-44 percent).
- Diarrhea (7-39 percent).
- Failed abortion (2-6 percent).
- Misoprostol & Tamoxifen:
- Vomiting (28 percent).
- Diarrhea (8 percent).
- Failed abortion (8 percent).
- Misoprostol Alone:
- Nausea (24 percent).
- Vomiting (25-26 percent).
- Diarrhea (58 percent).
- Headache (13-15 percent).
- Fever (35 percent).
- Chills (54-57 percent).
- Failed abortion (6-8 percent).
Complications associated with instillation techniques are as follows:
- Hemorrhage requiring transfusion (0.32-1.72 percent).
- Infection.
- Incomplete abortion.
- Cervical laceration.
- Hypernatremia and sodium load (saline).
- Muscle necrosis (myometrial injection of saline or urea).
- Adverse GI effects.
- Unintended surgery (0.04-0.08 cases per 100 instillations).
- Disseminated intravascular coagulopathy (saline, 658 cases per 100,000 instillations).
Urea instillation abortions are reported to be safer than saline abortions. Prostaglandin-induced second-trimester abortions are safer than saline abortions and have a lower induction-to-completion time.
Of all methods of second-trimester abortion, the safest procedure (using mortality surveillance data) is dilation and extraction. Labor induction with prostaglandins and passive dilators has a higher risk than dilation and extraction due to the risk of retained placenta. Intermediate risk of mortality occurs with instillation procedures. The highest mortality rates for second-trimester abortions are associated with major surgical procedures (ie, hysterotomy, hysterectomy).
Selective reduction procedures are not included in the statistics for second-trimester abortions. For the rare condition of monochorionic twins, selective reduction cord occlusion techniques are reported by Challis et al to have premature rupture of membranes in up to 30 percent of cases. The more common method of intracardiac injection techniques for selective reduction is associated with premature rupture of membranes in 13 percent of triplet pregnancies reduced to twins and in 19.3 percent of quadruplets reduced to twins. The risk of miscarriage in a pregnancy undergoing selective reduction is inversely proportional to the number of fetuses in the initial pregnancy (i.e., quintuplet, 24.8 percent; triplet, 8.3 percent).
PROGNOSIS OF THERAPEUTIC ABORTION
Advantages of medical abortion are as follows:
- Can be performed without delay.
- Avoids anesthesia and surgical risks.
- Psychological advantage - Patient control.
- Wider availability of abortion services.
- Increased patient choice.
Advantages of surgical abortion are as follows:
- More effective than medical abortion.
- Shorter completion time.
- Shorter bleeding duration.
- No exposure to potential teratogens.
- Can be performed later in gestational age.
- Fewer visits.
Surgical abortion is 99 percent effective in terminating pregnancy. Medical abortion using mifepristone and misoprostol has a mean effectiveness of 94 percent. Medical abortion using methotrexate and misoprostol has effectiveness ranging from 88-96 percent. Medical abortion in the second trimester using misoprostol has effectiveness ranging from 40-89 percent within 24 hours. Instillation methods of abortion have effectiveness ranging from 81-86% at 48 hours to 97 percent at 72 hours.
As with all interventions, complications are associated with all the methods of termination of pregnancy. For complications associated with surgical abortion techniques, see above under Surgical Abortion Complications.
Medical abortions in the first trimester are very safe and well-tolerated procedures. The major problem is decreased efficacy with increasing gestational age. In the case of methotrexate, a long period of time between administration of medication to abortion is problematic.
First-trimester abortions performed by surgical or medical methods are well tolerated, have little effect on future fertility, and are not associated with long-term psychological consequences. Second-trimester abortions are well known to be associated with increased risk of morbidity and mortality with increasing gestational age. An association of increased risk for preterm delivery after dilation with metal dilators has been reported.
MOONDRAGON'S ABORTION INDEX
This index contains information about types of methods available for elective clinical abortions, reasons a particular method may be used, risks and possible complications, description of the various procedures and the expected outcomes. Post-procedural care information is given regarding general measures, medication, activity, and diet are discussed. I have also included links to pages regarding spontaneous abortions, also known as miscarriages, since these also involve pregnancy termination. Links are available to other related pages.
Due to several recent telephone inquiries from my website visitors, I must add this statement to my web pages in this section: MoonDragon Birthing Services is a holistic homebirth midwifery service and does not perform any type of pregnancy termination, contraception method, or ObGyn procedure or surgery discussed in these pages. I have gathered this information for the education of my visitors to my website so that they will be able to make informed decisions about their health care options. If you feel you are in need of any of these methods and/or services, you will have to find a practitioner in your region that will perform the type of procedure you are interested in having done.
A "must read" resource for more information about choices and women's rights to choose is:
Natural Liberty - Every Woman's Guide
Rediscovering Self-Induced Abortion Methods
By Sage-Femme Collective
(Full Digital pdf of this Book)
MOONDRAGON'S ABORTION LINKS
Important... These pages are for informational purposes only and do not replace important care given by your health care provider or instruction by a qualified practitioner.
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