Abortion
(Interruption of Pregnancy)
Induced abortion is the intentional ending of a pregnancy by
surgery or drugs.
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A pregnancy may be ended by surgically removing the contents
of the uterus or by taking certain drugs.
Complications are uncommon when an abortion is done by a
trained health care practitioner in a hospital or clinic.
Induced abortion does not increase risks for the fetus or
woman during subsequent pregnancies.
In the United States, about 50% of pregnancies are
unintended. About 40% of unintended pregnancies are ended by induced abortion,
making it one of the most common surgical procedures done. About 90% of
abortions are done during the 1st trimester. States may set restrictions (such
as mandatory waiting periods, age of the fetus, or notarized consent for
minors). These restrictions may delay or prevent access to abortion.
In countries where abortion is legal, complications are
rare. Worldwide, about 13% of deaths in pregnant women are due to abortion.
Most of these deaths occur in countries where abortion is highly restricted or
illegal.
Pregnancy is confirmed before an abortion is started. Often,
ultrasonography is used to determine the age of the fetus, but sometimes a
health care practitioner's evaluation can determine the age during the 1st
trimester. If women have risk factors for problems related to an abortion (such
as heart or lung disease, seizures, or a history of cesarean deliveries), they
may require further evaluation.
Did You Know...
Abortion is one of the most common surgical procedures done
in the United States.
Contraception can be started immediately after an abortion
done before 28 weeks of pregnancy.
Methods of Abortion
Abortion methods include
Surgical abortion (surgical evacuation): Removal of the
contents of the uterus through the cervix
Drugs to cause (induce) abortion: Use of drugs to stimulate
contractions of the uterus, which expel the contents of the uterus
The method used depends in part on how long a woman has been
pregnant. Ultrasonography is usually done to estimate the length of the
pregnancy. Surgical abortion can be used for most pregnancies up to 24 weeks.
Drugs can be used for pregnancies that are less than 11 weeks (often called
medication abortion) or that are more than 15 weeks (often called induction).
For abortions done early in the pregnancy, only a local
anesthetic may be needed. Conscious sedation (drugs that relieve pain and help
women relax but allow women to remain conscious) may also be used. Rarely, a
general anesthetic is needed.
Before a surgical abortion, women are given antibiotics that
are effective against infections in the reproductive tract.
After any abortion (surgical or medication), women with
Rh-negative blood are given injection of Rh antibodies called Rho(D) immune
globulin. If the fetus has Rh-positive blood, a woman who has Rh-negative blood
may produce antibodies to the Rh factor. These antibodies can destroy the
fetus's red blood cells. Treatment with Rho(D) immune globulin reduces the risk
that the woman's immune system will make these antibodies and endanger
subsequent pregnancies. Treatment with immune globulin may be optional before 8
weeks of pregnancy.
Surgical abortion
The contents of the uterus are removed through the vagina.
Different techniques are used depending on the length of the pregnancy. They
include
Dilation and curettage (D and C) with suction
Dilation and evacuation (D and E)
Dilation refers to widening the cervix. Different types of
dilators may be used, depending on how long the pregnancy has lasted and how
many children the woman has had. To reduce the possibility of injuring the
cervix during dilation, doctors may use substances that absorb fluids, such as
dried seaweed stems (laminaria) or a synthetic dilator. Laminaria are inserted
into the opening of the cervix and left in place for at least 4 hours,
sometimes overnight. As the dilators absorb large amounts of fluid from the
body, they expand and stretch the opening of the cervix. Drugs such as
misoprostol (a prostaglandin) can also be used to dilate the cervix.
Typically for pregnancies of less than 14 weeks, dilation
and curettage (D and C) with suction is used. A speculum is used in the vagina
to enable the practitioner to see the cervix. A local anesthetic (such as
lidocaine) is injected into the cervix to reduce discomfort, and the cervix is
dilated. Then a flexible tube attached to a vacuum source is inserted into the
uterus to remove the fetus and placenta. The vacuum source may be a handheld
syringe or similar instrument or an electrical suction machine. Sometimes a
small, sharp, scoop-shaped instrument (curet) is inserted to remove any
remaining tissue. This procedure is done gently to reduce the risk of scarring
and infertility.
For pregnancies between 14 and 24 weeks long, dilation and
evacuation (D and E) is usually used. After the cervix is dilated, suction and
forceps are used to remove the fetus and placenta. A sharp curet may be used
gently to make sure all products of conception have been removed.
If women wish to prevent future pregnancies, contraception,
including a copper or levonorgestrel-releasing intrauterine device (IUD), can
be started as soon as the abortion is completed.
Medication abortion
Drugs to induce abortions may be used for pregnancies of
less than 11 weeks or more than 15 weeks. For an abortion during early
pregnancy (less than 11 weeks), the abortion process can be completed at home.
For an abortion later in pregnancy, the woman typically is admitted to the
hospital to take the drugs that will induce labor.
Practitioners confirm the completion of the abortion by one of the following:
Ultrasonography
A urine test to measure human chorionic gonadotropin (hCG)
on the day the drug is given and 1 week later (hCG is produced early in
pregnancy)
After a medication abortion, a urine pregnancy test 5 weeks
Prostaglandins are hormonelike substances that stimulate the
uterus to contract. They may be used with mifepristone. Prostaglandins may be
held in the mouth (next to the cheek or under the tongue) until they dissolve
or placed in the vagina.
For abortions in pregnancies that have lasted less than 11
weeks, the most common regimen involves taking mifepristone tablet, followed by
misoprostol taken 1 to 2 days later. Misoprostol is held next to the cheek
until it dissolves, or it is placed in the vagina. The woman may take
mifepristone and misoprostol on her own or have a doctor give it to her. This
regimen causes abortion in about
95% of pregnancies that have lasted 8 to 9 weeks
87 to 92% of pregnancies that have lasted 9 to 11 weeks
An additional dose of misoprostol improves effectiveness in
pregnancies that have lasted longer than 9 weeks.
If a medication abortion is unsuccessful, a surgical
abortion may be required.
Induction is a term often used when drugs are used to induce
abortions in pregnancies that have lasted more than 15 weeks. Women remain in
the clinic or hospital until the abortion is complete. Mifepristone tablets can
be taken, followed in 1 to 2 days by a prostaglandin, such as misoprostol, or
misoprostol can be taken alone.
Complications of Abortion
Complications from abortion are rare when it is done by a
trained health care practitioner in a hospital or clinic. Also, complications
occur much less often after an abortion than after delivery of a full-term
baby. Serious complications occur in fewer than 1% of women who have an
abortion. Death after an abortion is very rare. About 6 out of a million women
who have an abortion die, compared with about 140 out of a million women who
deliver a full-term baby.
The older the fetus is, the higher the number of
complications.
The risk of complications is related to the method used.
Surgical evacuation: Complications are rare when surgical
abortions are done by trained practitioners. The uterus is torn (perforated) by
a surgical instrument in fewer than 1 of 1,000 abortions. Injury of the
intestine or another organ is even rarer. Severe bleeding during or immediately
after the procedure occurs in 6 of 10,000 abortions. Very rarely, the procedure
or a subsequent infection causes scar tissue to form in the lining of the
uterus, resulting in sterility. This disorder is called Asherman syndrome.
Drugs: Mifepristone and the prostaglandin misoprostol have
side effects. The most common are crampy pelvic pain, vaginal bleeding, and
gastrointestinal problems such as nausea, vomiting, and diarrhea.
Either method: Bleeding and infection can occur if part of
the placenta is left in the uterus. If bleeding occurs or if infection is
suspected, practitioners use ultrasonography to determine whether part of the
placenta remains in the uterus.
Later, particularly if the woman is inactive, blood clots
may develop in the legs.
If the fetus has Rh-positive blood, a woman who has
Rh-negative blood may produce Rh antibodies—as in any pregnancy, miscarriage,
or delivery. Such antibodies may endanger subsequent pregnancies. Giving the
woman injections of Rho(D) immune globulin prevents antibodies from developing.
Immune globulin may be optional for pregnancies lasting less than 8 weeks.
Psychologic problems after an abortion are more likely if
the following are present
Psychologic symptoms before pregnancy
Limited social support or a sense of disapproval in their
support system