Elective Termination of Pregnancy

• In the United States, nearly 50% of all pregnancies are unintended and 40% of these end in elective abortion. Excluding miscarriages, 22% of all pregnancies are electively terminated.
• Of the over 1.2 million abortions performed annually in the United States, approximately 50% are performed on women in their 20s and 18% are performed on teenagers (<19 years of age).
• Abortion is a common procedure in the United States, with 3 in 10 women having the procedure done by the age of 45 years.
• Over 60% of women undergoing abortions have one or more children and 80% are unmarried.
• Caucasian women account for 36% of procedures; Black women for 30%; and Hispanic women for 25%.
• The most common reasons women give for choosing to have an abortion


  Financial burden, familial obligations, interference with work or school, and desire to avoid single parenting
• Since the legalization of abortion in 1973, the risk of death from abortion has declined by 85%.
• The most recent maternal mortality rate for induced abortion in the United States is 0.1 per 100,000.
• This is in comparison to a maternal mortality of 7.7 per 100,000 for completed pregnancy and delivery.
• The major causes of abortion mortality are complications of hemorrhage and infection, followed by thromboembolism and anesthetic complications.
• In general, maternal morbidity is lowest if abortion is performed before 8 weeks' gestation.
• Less than 0.3% of abortions performed in the first trimester result in complications that require hospitalization.
• Procedures for termination of pregnancy

  • Suction curettage (D&C)
  • Manual vacuum aspiration
  • Nonsurgical "medical" abortion using either mifepristone or methotrexate
  • Surgical evacuation of the uterus
  • Medical induction of labor
• Approximately 88% of induced abortions are performed in the first trimester of pregnancy (75% prior to 9 weeks), utilizing a surgical evacuation of the uterus (D&C).
• Nearly 95% of all induced abortions are performed before 16 weeks' gestation, 4% are performed between 16 and 20 weeks' gestation, and less than 1.5% is performed after 21 weeks' gestation.
• Laws vary from state to state, but generally, terminations are performed up until the fetus has reached viability at about 24 weeks' gestation. After week 24, abortions are generally only performed when necessary for the preservation of maternal life.
• In 2000, 87% of counties in the United States had no access to an abortion provider.
• Suction curettage (D&C)


  Mechanical dilation of the cervix and removal of the products of conception using a suction cannula
• Suction curettage


  • Safe and effective means of terminating a pregnancy between 7 and 13 weeks of gestation
  • Used for 87% of all induced abortions
• Manual vacuum aspiration


  Insertion of a 4- to 12-mm cannula into the cervical os and manual extraction of the uterine contents using a vacuum syringe
• Mifepristone (RU 486)


  Synthetic progesterone receptor antagonist that disrupts the pregnancy by making the endometrial lining unsuitable to sustain the pregnancy
• Methotrexate


  Chemotherapeutic agent and dihydrofolate reductase inhibitor that interferes with DNA synthesis, thereby preventing placental villi proliferation
• Mifepristone can be used up to 63 days from the last menstrual period (LMP).
• The typical protocol for medical termination of pregnancy involves a single oral dose of mifepristone followed by a dose of misoprostol 24 to 48 hours later.
• Methotrexate is administered intramuscularly or orally within 49 days of the LMP, followed by misoprostol 6 to 7 days later.
• When used alone, the efficacy rate of mifepristone is approximately 65% to 85%. However, when given with misoprostol, the success rate is 92% to 98%.
• The efficacy rate of methotrexate with misoprostol for induced abortion is 94% to 96%.
• The efficacy rates of both mifepristone and methotrexate decline for pregnancies greater than 7 weeks' gestation.
• Methotrexate


  A chemotherapeutic agent that blocks dihydrofolate inhibitor that interrupts placental proliferation
• Mifepristone (RU 486)


  An abortifacient that blocks progesterone stimulation of the endometrial lining, thus causing detachment of the embryo
• Mifepristone and methotrexate


  Used in combination with a prostaglandin (often misoprostal) and have high efficacy rates (92% to 98%) for medical termination when used within 63 days of the LMP
• Dilation and Evacuation (D&E)

  1. Gradual dilation of the cervix to accommodate the larger volume of uterine contents

  2. Use of extraction forceps, suction, and sharp curettage to assist in complete evacuation of the uterus

  3. Typically performed using IV conscious sedation in combination with a paracervical block
• D&E


  • Similar to suction curettage (D&C) but requires wider cervical dilation and the use of special forceps and curets to assist with the extraction of the larger volume of fetal parts
• D&E


  Has lower maternal mortality and morbidity compared to induction of labor for second trimester abortions
• Complications of D&E


  • Cervical laceration
  • Hemorrhage
  • Infection
  • Uterine perforation
  • Retained tissue
• Induction of labor for second trimester abortion

  1. Cervical ripening with a prostaglandin

  2. Amniotomy

  3. Induction of labor with high-dose oxytocin
• Complications of induction of labor

  • Retained placenta
  • Hemorrhage
  • Infection
  • Cervical laceration
• Maternal morbidity is 4 in 100,000 for D&E and 8 in 100,000 for induction of labor compared to 7.7 in 100,000 for term pregnancy and delivery