Since the landmark 1973 Supreme Court decision legalizing abortion, hundreds of laws, federal and state, have been proposed or passed, making this the most actively litigated and highly publicized area in the field of medicine. Many of these laws are enjoined by court order and are thus not enforceable. They span a variety of controversial rulings: provisions to establish viability before termination, parental or spousal notification, mandatory waiting periods, mandatory wording for counseling sessions, denial of public funding, denial of public funds for counseling (“gag orders”), targeted regulations specific to abortion providers, and provisions against specific abortion techniques.

Laws in several states mandate the examination of fetal tissue, and it is yet unclear as to how these laws will apply to medical abortions. Since virtually all the laws regulating abortions were written before the legalization of medical abortions, some of these laws, such as the fetal tissue examination statutes, may be non sequiturs. Laws in some states criminalize these procedures; performing a specific abortion would constitute a felony offense by the provider. Thirty-one states have forced parental consent or notification. Nine state courts block these laws. Thirty-one states ban abortion coverage for low-income women, and 19 states pay for abortion for low-income women. A pending bill in Maryland proposed that hospitals provide emergency contraception to all rape victims who seek treatment. The Maryland legislature, however, adjourned in April 2002 without passing this bill.

In the context of international laws, restrictive regulations and laws do more to increase the morbidity and mortality associated with abortions and do not present alternatives to obtaining abortions. In states where the laws are very restrictive, there is a trend toward delaying abortion procedures until later gestational ages, which makes access to care harder to achieve and actually increases medical risk unnecessarily.

Before Roe v Wade

Before the 19th century, most states had no specific abortion laws. The provisions of British common law took precedence, and women had the right to terminate a pregnancy prior to viability. Beginning with a Connecticut statute followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and in some cases punishing the woman herself.

The first federal law on the subject was the notorious Comstock Law of 1873 that permitted a special agent of the postal service to open mail dealing with abortion or contraception in order to suppress the circulation of “obscene” materials. From 1900 until the 1960s, abortions were prohibited by law. However, the Kinsey report noted that premarital pregnancies were electively aborted, and public and physician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.

In 1965, there were 265 deaths due to illegal abortions. Twenty percent of all pregnancy-related complications in New York and California were due to abortions. A series of Supreme Court decisions granted increased rights to women and assured their right to autonomy in this process. No decision was more important than Griswold v Connecticut, which in 1965 recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain contraceptives from their provider.

Roe v Wade

Roe v Wade was the culmination of the work of a wide consortium of individuals and groups who collectively crafted a strategy to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL). The movement lawyers were committed to universal access to rights at a time when states were gradually liberalizing pertinent laws. Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff “Jane Roe.” Although the ruling came too late for McCorvey’s abortion, her case was successfully argued before the Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.

In 1973, in an opinion written by the Nixon Supreme Court appointee Harry Blackmun, the court ruled that a woman had a right to induced abortion during the first 2 trimesters of pregnancy. He cited the safety of the procedures and the fundamental right of women to be free from the states’ legislation concerning their medical decisions in the first trimester of pregnancy.

Blackmun, writing for the majority, sidestepped the question of viability, specifically stating that scholars in many respected disciplines could not resolve this issue. Therefore, he felt that the court need not resolve this either. Since this ruling, the states have regained much control, and serious restrictions have been placed on abortion services. The Hyde amendment in 1976 prohibited use of federal funds for abortions, except in the case of maternal life endangerment. Since then, it is estimated that up to a third of public funding recipients cannot obtain an abortion because of lack of funds.

Viability determinations

Loosely defined, the term viability is the fetus’ ability to survive extrauterine life with or without life support. A number of landmark Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri’s requirement for preabortion viability testing after 20 weeks’ gestation. However, no reliable or medically acceptable tests exist for this prior to 28 weeks.

The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial because of its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to account for the variability of viability by inserting language recognizing that some fetuses never attain viability (eg, anencephalics). In Colautti v Franklin, the court overturned a Pennsylvania law requiring physicians to follow specific directives in certain medical circumstances and recognized physician judgment as sacrosanct and important.

Parental consent

Parental consent is not required in the case of carrying a pregnancy to term, seeking contraception, or being treated for a variety of conditions, including sexually transmitted diseases. In 2 decisions handed down in 1991, Hodgson v Minnesota and Ohio v Akron Center for Reproductive Health, the Supreme Court held that it is legal to have parental notification laws for abortions. These provisions often include waiting periods and fairly limited provisions for judicial bypass. On February 12 the West Virginia Senate Health and Human Resources Committee passed a bill requiring women seeking an abortion to give informed consent and wait for at least 24 hours before undergoing the abortion procedure. Specifically, the women must be furnished with written material, printed by the state, that would outline alternatives to abortion and the potential risks of the procedure.

On February 21, the Kentucky Senate passed two abortion-related bills. SB 151 makes the existing consent laws more rigorous by requiring a woman to meet with a provider in person to receive pre-abortion counseling.

Sociologic research shows that most minors do involve their parents in their decision to abort (45%). However, these laws have fostered a new ominous trend: minors obtaining abortions significantly later in their pregnancies and often traveling great distances to states with no such law.

Intact dilation and extraction

The recently crafted political term "partial-birth abortion" loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This delineation is so overly broad that both legal and expert gynecologic testimony claim this definition encompasses virtually all methods of second trimester abortion including dilation and extraction and inductions.

In 19 states, laws have banned these procedures; in only eight states are these laws enforced. In his first administration, President Clinton vetoed 2 bills banning such abortions. The Supreme Court ruled on June 28, 2000 that the Nebraska law and all other laws banning partial-birth abortion are unconstitutional. The reasons for the Supreme Court’s decision was that the Nebraska law did not contain an exception to protect the health of the mother, and the law also was thought to “unduly burden” a woman’s choice to end her own pregnancy.

Recently, the Department of Justice filed an amicus brief, on behalf of the Bush administration, asking the Sixth United States Circuit Court of Appeals to reverse a decision by a lower court which struck down the Ohio Ban on Late-term abortions. This ban was struck down by US District Court Judge, Walter Rice because the legislation does not allow for the procedure when a woman’s life is in danger.

Similarly, in Stenberg v Carhart, the Supreme Court struck down Nebraska’s ban on late term abortions for the same reason—because it may be necessary if a woman’s life is in danger. However, the Department of Justice states the Ohio ban is constitutional because it includes the provisions set up by the Supreme Court in Stenberg.

Providers

Providers of elective induced abortions are generally obstetricians and gynecologists. However, many studies have illustrated the safety of allowing a variety of practitioners of various disciplines, both physician and nursing, to perform these procedures.

Various factors over the years have influenced the number of providers. Abortion is the only common surgical procedure that is elective in obstetric and gynecologic residencies. Thus, few board-certified gynecologists are actually qualified to perform the procedure. Increasing violence against providers and clinics has further decreased providers’ willingness to provide abortion services. There has been a “graying” of providers who continue to perform abortions. Most represent an older population of clinicians who became committed in providing access to safe, legal abortions after caring for young women who suffered or died from complications of an illegal abortion. For example, the number of abortion providers decreased by 14% between 1992-1996, suggesting a number of physicians retired and new physicians were not taking on the abortion services. The lack of abortion providers is underscored by the fact that 86% of counties in the United States have no abortion services.

New York City Mayor Michael Bloomberg (R) proposed a policy that will include abortion training for medical residents in all 11 of the city’s hospitals. Recently, there has been a decline in the number of abortion providers in the United States because of the aging population of providers and the lack of training during residency. Students of course are able to opt out of the training if they are morally opposed to abortion. In contrast, the Kentucky Senate also passed a bill that allows pharmacists who oppose abortion to opt out from dispensing medical abortion pills.

Medical abortion protocols have the potential to expand the number of available providers, as it is only necessary to arrange for backup with a provider who can perform a surgical abortion and it is unnecessary to have a staff willing to assist at a surgical abortion. The role of nurse practitioners, with valid prescription privileges, is unclear at the present time, but these providers may aid in expanding abortion access as well.

The development of more advanced surgical techniques has allowed for safe second trimester terminations and, statistically, more of these have been performed. The Food and Drug Administration (FDA) recently has given approval to Mifeprex (mifepristone, RU-486) for medical abortions. Multiple regimens for medical terminations using medications approved by the FDA for indications other than termination of pregnancy have come into use. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination. This may be difficult to track statistically but may actually lead to an increased number of abortions in the United States.

A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States. An understanding of the laws (enacted, enjoined, and pending) on local and federal levels is important to providers, and these legal ramifications are reviewed in this chapter as well (see Medical/Legal Pitfalls).

Abortion postoperative care often is provided at sites that did not perform the termination of pregnancy, and strategies for follow-up care for women whose pregnancies have been terminated are important for all providers of primary care for women.

Pathophysiology:

Surgical termination

The development of accurate over-the-counter (OTC) pregnancy tests allows for the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in this very early time frame have been termed "menstrual extractions,” a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed extremely early suction evacuations without histologic tissue confirmation, allowing for maximum confidentiality for both patient and provider.

Abortions performed prior to 9 weeks from last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. From 9 weeks until 14 weeks, an abortion is performed by a dilatation and suction curettage procedure. After 14 weeks, surgical abortions are performed by a dilatation and evacuation procedure. After 20 weeks of gestation, abortions can be performed by labor induction, prostaglandin labor induction, saline infusion, hysterotomy, dilatation and extraction, or intact dilatation and extraction. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.

Medical termination

Medical abortion is a term applied to a medication-induced elective abortion. This can be accomplished with a variety of medications administered either singly or in succession. Medical abortion has a success rate that ranges from 75-95%, with about 2-4% of failed abortions requiring surgical abortion and about 5-10% of incomplete abortions, depending upon the stage of gestation and the medical products used. For a review of multiple studies see Kahn et al 2000. Patients who select a medical abortion express a slightly greater satisfaction with their route of abortion and, in the majority of cases, express a wish to choose this method again should they have another abortion. Research needs to be done to more clearly establish which protocol is best, which medications are preferable, and how successfully women and adolescents can diagnose a complete versus an incomplete abortion.

Although a critical shortage of providers to provide surgical abortions exists, in a recent study by Koenig et al providers who do not perform surgical abortions have indicated a willingness to provide medical abortions.

Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Some patients require an emergency surgical abortion, and for safety concerns, patients undergoing medical abortions need access to providers willing to perform an elective termination.

The in September of 2000 the FDA approved mifepristone (RU-486) for use in a specific medical regimen that includes misoprostol administration for those who do not abort with mifepristone alone. Methotrexate and misoprostol are approved drugs for other indications that can be used for medical termination of pregnancy. Additional research will determine exactly which regimen is the best for medical abortions.

Medical abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed the patient must be seen for evaluation of the completeness of the process.

Frequency:

• In the US: Abortion statistics are available from a variety of sources, including, the CDC, the Alan Guttmacher Institute, and the National Abortion Federation. Information and specific instructions regarding state requirements for abortion reporting are available from vital statistics offices in each state health department. Comprehensive statistical information is regarded as important in ensuring the utmost in patient safety (Centers for Disease Control and Prevention).

  In 1996, approximately 20 women for every 1000 women aged 15-44 years had an abortion, and for every 1000 live births, approximately 325 abortions were performed (see Centers for Disease Control and Prevention). In the past 20 years, considerable progress has been made in the technology used for second trimester abortion. This and the social milieu of abortion have led to more women seeking terminations later in pregnancy. For the current facts regarding abortions performed in various states at various times in the pregnancy, see Centers for Disease Control and Prevention.

• Internationally: Globally, abortion mortality accounts for at least 13% of all maternal mortality. New estimates are that 50 million induced abortions are performed each year in developing countries, with some 20 million of these performed unsafely because of conditions or lack of provider training. Maternal mortality is 600,000 per year due to pregnancy-related causes, and 99% of these deaths are in developing countries.

Mortality/Morbidity: The safety of abortion is well established, with infection rates less than 1%, and less than 1 per 100,000 mortalities occurs from first-trimester abortions. At every gestational age, elective abortion is safer for the mother than carrying a pregnancy to term.

Race: In 1996, of the women who obtained legal abortions, 59.1% were white, 35, 2% were black, and 5.7% were other (of the other, 16.1% were Hispanic). These data can be seen at http://www.cdc.gov/nccdphp/drh/pdf/48ss4_tbl1.pdf.

• With advances in perinatal care, few medical contraindications to pregnancy exist. Perinatologists, obstetricians, and abortion counselors prefer to put the risks in the context of statistical likelihood of complications and then let the patient make her final decision.

• Women take on less risk, regardless of health or gestational age, to terminate a pregnancy than to continue to term. These abortions have been termed therapeutic abortions.

• Maternal medical conditions that carry significant risks in pregnancy include severe diabetes with retinopathy, cardiac or renal complications, advanced cardiac disease, renal failure, sickle cell disease, autoimmune disease, and psychiatric disease.

• Cardiac conditions that still carry maternal mortality rates of 5-15% include severe mitral stenosis, coarctation of the aorta, uncorrected tetralogy of Fallot (TOF), aortic stenosis, myocardial infarction history, and presence of artificial heart valves. Greater mortality rates have been reported in women with coarctation of the aorta with vascular involvement, pulmonary hypertension, Marfan syndrome with aortic involvement, and myocardial infarction in pregnancy.

• Nondirective counseling can help a woman select her choice.

• Fetal indications for abortion

• Fetal conditions that are incompatible with life include anencephaly, trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly, and some hydrocephalic cases.

• Many hypoplastic cardiac conditions also are incompatible with life. However, with cardiac transplantation, some infants now can survive birth with these defects.

• Anomalous conditions that are common and encountered in abortion counseling include most fetal cardiac anomalies, trisomy 21, open and closed neural tube defects, limb, face, or cleft abnormalities, esophageal or duodenal atresia, chest and abdominal wall defects, cystic kidneys or hydronephrosis, intracranial calcifications suggestive of viral disease, or diaphragmatic defects.

Physical:

• A brief physical examination usually is conducted prior to an abortion procedure. The focus is on dating the pregnancy, ensuring the absence of other gynecologic pathology, particularly STIs, and assessing the patient's suitability for an operative procedure under local sedation.

• Note any vaginal or cervical discharge, the nature of the cervix, and any lesions. Document the presence or absence of any ovarian pathology.

• If the patient is going to have general anesthesia, a typical screening preoperative physical can be performed.
  
  

Lab Studies:

• Preabortion workup

• Pregnancy tests are used to confirm the presence of a pregnancy, and home tests are reliable enough to accept their results in some cases.

• Hemoglobin (Hb) or hematocrit (Hct) levels always are assessed. Full CBC is optional but may be indicated if abnormalities are detected with the Hb or Hct test.

• STI screening typically includes a test for gonorrhea culture (GC) or chlamydial test (CT). Screening for other STIs, such as syphilis or HIV disease, is usually prohibitively expensive, but patients who are found to have GC or CT should be offered these tests.

• Rh typing is always performed. ABO typing is optional.

• Use of human chorionic gonadotropin titers

• Human chorionic gonadotropin (HCG) titers are helpful in performing very early terminations, to establish the completeness of an abortion postoperatively in cases of a persistent positive urinary pregnancy test, or to establish the presence of an ectopic pregnancy. In medical abortion protocols they can also be used to establish the arrest of viability of a pregnancy, or to establish the completeness of a medical abortion.

  Titer resolution is different between surgical and medical abortions. The titer should decrease to approximately 64% of its preabortion value within 24 hours of misoprostol being administered in medical abortion protocols. By 2 weeks, the titers should have dropped 99%.

• If an abortion is being performed prior to 5 weeks from LMP, titers preoperatively can be very useful. Managing most abortion procedures without an HCG titer is within the standard of care.

• Wet preparations

• Vaginal wet preparations, pH testing, or urine dipstick analysis usually are performed for standard indications.

• If a woman is discovered to have a concomitant infection, it may need to be treated before she has the abortion.

Imaging Studies:

• Ultrasonography is invaluable but not always used in first trimester terminations. Standard of care demands that second trimester terminations be evaluated preoperatively with sonography. Documenting uterine abnormalities is important because failed terminations can occur in patients with double uterus or ectopic pregnancies.

Medical Care: Once the pregnancy has been confirmed, gestational age has been established, and the patient has decided to abort, the procedure offered typically reflects the patient's stage of gestation. Early abortions can be accomplished medically or surgically, but most facilities do not have the technical ability or the protocols established to offer medical abortions. Therefore, most abortions are performed surgically.

• Preoperative care of patients undergoing surgical abortion
  • Women often travel far for their abortion procedure and feel comfortable completing the preoperative preparation in a short office visit. In states where laws require waiting periods, this can be done in stages.

  • The assessment process only involves a targeted history, physical, laboratory work, and ultrasound evaluation (including dating of the pregnancy, if indicated) followed by a counseling session.

  • Second trimester pregnancy preparation is more difficult. It is almost impossible to prepare the cervix in less than 24 hours, but the basic assessment process is identical.

  • Ultrasound examinations should involve a more extensive examination looking specifically for obvious fetal anomalies (see Imaging Studies).

  • Some centers also offer an intra-amniotic injection of digoxin 1 mg, which ceases fetal cardiac activity and has very low transplacental medication leakage, so it has been shown to be safe for the mother. This ensures fetal death prior to fetal expulsion regardless of method of second trimester abortion.

• Abortion counseling
  • Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing to term, information and options for the technique of the abortion procedure, and, finally, information regarding a contraceptive decision. Now that medical protocols are becoming more widely available, the risks and benefits of both medical and surgical abortions should be reviewed.

  • The counseling process is aimed primarily at the woman herself, as well as those she chooses to have involved. Studies indicate that males are involved in more than 40% of the decisions, but only scant research has been done on male involvement in the process. Some women can reach a decision quickly; others take longer to decide. The counseling process should offer referrals for those who need ongoing support.

  • Of utmost importance is to ensure that the patient has had enough time to consider her options and that she is not being coerced into her decision.

  • Many strategies can be used in the counseling session. Open-ended questions bring out issues that are pertinent to the woman and encourage meaningful exchange of dialogue. The patient's emotions should be validated, and the counselor should encourage the client to explore her feelings in more depth. Health care providers and counselors may not have the time or the expertise to devote themselves to lengthy sessions, and not all women are able to complete the process in a day if these issues need to be explored before the abortion procedure.

  • Some state laws may apply to the counseling process. Some states have mandatory waiting times between the information session and the actual abortion, other states require family or parental notification, and some states mandate that certain subjects be covered. Laws directed towards the providers usually also exist. Providers have an obligation to find out about their local laws and to comply with them.

• First and second trimester medical abortion
  • First trimester terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or Mifeprex (RU-486) with or without misoprostol. Other prostaglandins are in use in other countries.

  • Medical abortions are indicated for women who consent to a medical abortion but also are willing to undergo a surgical abortion if the medical abortion fails. Gestational age usually is less than 42-49 days, but many protocols including up to 63 days from LMP are in the literature. Literature has also documented safety of medical abortion protocols between 11-13 weeks is accumulating. Only scant reports exist of continuing pregnancies after misoprostol, but the current data do not suggest a teratogenic action of misoprostol exposure during pregnancy.

  • Contraindications to medical abortion vary depending upon the regimen selected. Contraindications to mifepristone, include serious medical problems, such as cerebrovascular or cardiovascular disease, severe liver, kidney or pulmonary disease, preoperative anemia (<10 mg/dL), undiagnosed ectopic pregnancy allergies contraindications to prostaglandin use, active uterine bleeding, or large uterine leiomyomata.

  • The Mifeprex/misoprostol appointment schedule is as follows: On day 1, Mifeprex 600 mg PO is administered in the office. On day 3, misoprostol 400 mcg PO or vaginally is administered at home and with 4 hours of observation. Between days 12 and 20, the patient returns to the office to determine if the abortion has been completed. If it has not, repeat misoprostol is administered or the patient may undergo a surgical abortion.

  • The methotrexate/misoprostol regimen is similar. Methotrexate is injected on day 1. On days 6-7, misoprostol is taken at home vaginally, and the patient returns to the office on day 8 to determine if the abortion has taken place. Misoprostol can be repeated and the patient monitored, or surgical abortion may be completed.

• Prostaglandin-induced second trimester abortion

• Prostaglandin can be administered vaginally, orally, or via extraovular or intra-amniotic infusion. The intra-amniotic route was associated with greater rates of uterine rupture, although rarely, and has been abandoned largely in favor of the safety and technical ease of oral or vaginal administration.

• In a recent comparison study by Perry of intra-amniotic 15-methyl-prostagalin F2-alpha and intravaginal misoprostol, the mean evacuation time was slightly less in the intra-amniotic group, and the rate of success by 24 hours was higher in the intra-amniotic group. The total complete abortion rate and incidence of severe effects were similar in both groups.

• Saline-induced abortion: Twenty years ago, saline-induced abortion was the only viable means of aborting a mid–second trimester pregnancy, and most of the literature regarding this technique is from that era. The process was long, laborious, had some potentially serious adverse effects, and has been abandoned for the greater maternal comfort offered by the dilatation and extraction procedures that subsequently have been developed. However, dilatation and extraction procedures are risky in the hands of inexperienced providers or providers who do not perform the procedures often enough to maintain competency. In these circumstances, the saline induced abortion can be safely used.

Surgical Care: Documentation is an important part of the surgical procedure. Preoperatively prepared standard operative reports are the standard of care and should include documentation of several important features including the patient's anatomical assessment (including uterine size), the procedure and instruments used (including the size of the dilators and the cannula used), the amount of blood loss, and the amount of tissue obtained.

• Cervical dilatation and preparation: Women having first trimester terminations, particularly those at less than 10 weeks’ gestation, rarely need preoperative cervical preparation. For those in the later part of the first trimester, preoperative dilatation with laminaria or medical treatment with prostaglandins is helpful and should be at the discretion of the provider performing the abortion. In the second trimester or beyond, the cervix needs preparation. Forceful cervical dilatation can lacerate the cervix, which can cause significant bleeding or in rare cases lead to cervical incompetence.
  • Laminaria: Laminaria japonicas are small sticks of presterilized seaweed that can be inserted preoperatively to dilate the cervix. They are generally thought to do this by absorbing water and swelling mechanically. Some believe that other hormonal mechanisms are triggered, allowing the cervix to dilate above the physical size of the laminaria. Only one laminaria is required for dilating the cervix with a 10-week pregnancy. As the weeks and the amount of dilatation the pregnancy termination requires progress, more laminaria are inserted and left for longer amounts of time. Most laminaria need at least 4 hours to be useful, but overnight use is indicated in cases that are further along. Successive applications of increased numbers of laminaria can be used for more than 24 hours if the pregnancy is very advanced or if the cervix is unusually rigid.

    Prior to insertion, Betadine preparation of the cervix is performed. Laminaria insertion is simple, often requiring a single-toothed tenaculum to stabilize the cervix and no anesthesia. For cases in which several laminaria must be inserted, 12 cc of lidocaine administered paracervically can provide comfort. The patient must understand that laminaria insertion is the beginning of the abortion procedure. Pregnancies have safely been carried to term after laminaria insertion and removal, but late onset intrauterine infection or chorioamnionitis is a concern. Counseling is used to be sure the patient understands her risks once she starts the dilatation process.

  • Failure to dilate: Failure to dilate the cervix is not common, but if no dilators (the smallest is a 3 mm) or laminaria can be admitted, this is the diagnosis. Rare cases exist in which the cervix is so scarred, mostly from previous pregnancies or deliveries, that the os cannot be viewed; the patient may be advised to have a medical abortion. Waiting until the patient is further in pregnancy is an option, as is dilating while watching with sonographic control.

• Intraoperative care of patients undergoing surgical abortion
  • Most patients having an early termination of pregnancy can have their abortion performed under "vocal sedation" (talking the patient through the procedure) as well as local sedation. Most patients do not need an intravenous access for medication.

  • If heavy sedation is selected, then intravenous fluids with lactated Ringer solution or one half normal saline are suitable, at rates appropriate for the patient's age and weight.

  • If a patient is administered intraoperative sedation, appropriate monitoring includes vital sign assessment, assessment of the patient's degree of sedation and responses, and assessment of the patient's pulse oxygen level.

• First trimester surgical abortion
  • Early terminations are performed with little cervical dilatation and using a hand held syringe or a small bore cannula attached to a suction machine. Abortions performed with a syringe are referred to as manual aspirations. Some authors still call them "menstrual extractions," from the days when abortion was more stigmatized and women did not want the procedure referred to as an abortion. Those performed with the suction generated by a vacuum aspirator are referred to as a vacuum aspiration. Both procedures take only a few minutes.

  • Single-toothed tenaculums are used to grasp the cervix after it has been prepared with Betadine. Local anesthetic is administered in a paracervical fashion. The agent used is usually lidocaine 1-2% or Nesacaine 1%. No epinephrine is necessary. The local anesthetic takes effect rapidly, and studies of the exact route of administration (several spots around the cervix or at 3 and 9 o'clock) have not shown large differences in efficacy.

  • For gestations of 6 weeks or less, cannulas of 3-6 mm can be used. For gestations of 7-9 weeks, 5-9 mm cannulas are used. The suction cannulas can be soft or rigid, straight or bent, and experienced providers can use either type interchangeably. Both suction syringes and the suction machines generate 60-70 mm Hg of pressure. Performing procedures at lower levels of suction prolongs the procedure and, therefore, increases bleeding and patient discomfort.

  • The amount of tissue obtained correlates with the stage of gestation and the fetal number. The amount of bleeding can be very slight, 5-25 cc for very early terminations, or as heavy as 100-250 cc. Amounts over 200 cc blood loss usually are indicative of uterine atony. Cervical lacerations increase the amount of blood lost.

  • Intravenous sedation with versed 2.5-5 mg can be performed, and rapidly acting narcotics can be supplemented for pain relief. Others have had success with sublingual diazepam, and intramuscular Toradol (ketorolac tromethamine) can be used.

  • Abortions in the late first trimester are performed with or without preoperative cervical dilatation with laminaria or misoprostol. If a woman is multiparous, no preoperative dilatation is usually necessary, although procedures under local anesthetic are more comfortable if the cervix has been prepared.

  • Sounding should be performed with the cannula to protect the uterus against perforation. The actual evacuation is performed by applying suction to the syringe or via the machine. The completeness of the procedure is ensured by the feel of the uterus against the instrument, the sound of the uterine curettage, and the appearance of bubbles in the cannula. Sonographic confirmation of completeness is helpful in some cases. The procedure takes a few minutes to complete, and the estimated blood loss should be minimal (5-10 cc range for very early abortion and 50-100 cc range for later procedures).

  • Tissue inspection for completeness is an essential part of the procedure.

• Dilatation and curettage
  • This specifically is a term that usually is applied to a diagnostic gynecological procedure or the treatment of an incomplete abortion.

  • The procedure usually is accomplished with similar dilatation procedures, but the uterine emptying is accomplished with a sharp metal curette. These curettes are more dangerous than the flexible or rigid plastic devices, which are used in the suction procedures, and are not recommended for abortion procedures.

• Second trimester dilatation and evacuation
  • Dilatation and evacuation is the safest and most common method of second trimester termination for experienced providers. These procedures are accomplished with similar preoperative preparation to first trimester preparation; however, the dilatation must be accomplished over hours and, in some cases, days. See Preoperative care of patients undergoing surgical abortion.

  • The procedure requires the cervix to be dilated to 2-3 cm, admitting at least a #16 Hegar dilator or a size 53 French (Fr) dilator. The cervix is grasped with a single-toothed tenaculum after Betadine preparation. The procedure is accomplished using a combination of suction curettage and manual evacuation of the fetus and placenta. Ultrasonic guidance is valuable, and some providers use manual palpation of the fundus to guide the use of the forceps that are used for evacuation. The forceps are used most carefully in the lower uterine segment. The types of forceps used are Soper, ring, or packing forceps, with Soper forceps being the most useful. Uterotonics can help push the products of conception toward the internal os to facilitate the process.

  • The procedure is longer and more uncomfortable than a first trimester procedure, but many patients can comfortably go through the procedure with local anesthesia. Blood loss for these procedures is in the range of 100-350 cc.

• Dilatation and extraction
  • This procedure is accomplished by cervical preparation similar to cases of dilatation and evacuation, but the fetus is removed in a mostly intact condition. The fetal head is made of cartilage and is able to be collapsed after the contents are evacuated so that it may pass through the cervix.

  • Very few providers perform the procedure. It usually is reserved for cases of maternal medical complications or fetal abnormalities.

  • With an intact fetus, the family may hold their baby and have time to say good-bye as part of the grieving process. Reconstituting the fetal head with a jellied substance can restore fetal anatomy.

  • The procedure also has been referred to as intact dilatation and extraction and has been called "partial birth abortion" by abortion opponents.

• Induction of labor
  • Most physicians have experience with the standard Pitocin protocols for labor induction, and these can be used in the case of a second trimester of pregnancy.

  • Premature rupture of membranes is one indication for this method.

  • Research generally indicates better success with prostaglandin methods, and this method typically is not employed.

• Hysterotomy
  • Hysterotomy is reserved for very few cases. Large uterine leiomyomata has been an indication for hysterotomy in the performance of an abortion, and in the past, placental previa was another indication (recent reports have shown that a dilatation and evacuation procedure can be performed safely in some of these cases).

  • The uterine segment is never developed well enough to place the incision there, so virtually all hysterotomies must be performed by classic uterine incisions.

• Hysterectomy: Very few indications exist for the use of hysterectomies to terminate pregnancies. The extra uterine vasculature that develops in pregnancy makes hysterectomy more dangerous, and the incidence of hemorrhage and complications rises.

• Surgical sterilization: Bilateral tubal ligation via minilaparotomy, tubal fulguration, or tubal device occlusion is easily performed at the time of first or second trimester abortion of pregnancy. Failure rates are high because of the enlarged tubal structure and lumen, but the magnitude of risk is not well established.

Consultations: The counseling process should offer referrals for those who need ongoing support.

Diet: Patients may eat a regular diet.

Activity:

• Tampons, douche, and intercourse should be avoided for one week.

• Heavy activity or lifting should be avoided for a few days.

• Patients that must have their termination performed by hysterotomy or hysterectomy are hospitalized according to the needs of their operation.

• Patients with a medical complication of pregnancy termination, such as a perforation, are cared for according to the treatment necessary.

• For the patient who has a fundal perforation, with an instrument that is not connected to suction, patient observation may be indicated but usually is not necessary.

• Patients with perforations suspicious of bowel injury may need exploratory surgery via laparoscopy (if the physician is an extremely experienced laparoscopist) or an exploratory laparotomy. If these procedures are used, hospitalization may be required for 1-3 days to manage the usual postoperative course.

• Antibiotic prophylaxis is recommended for any additional surgery with broad-spectrum antibiotic coverage administered over at least 24 hours.

Further Outpatient Care:

• Postoperative care of a patient after surgical abortion

• Observe patients for a half an hour, checking for abdominal pain, unusual bleeding, and observing vital signs.

• Anti-D immunoglobulin should be administered on the day of the procedure to patients who are Rh-negative.

• Patients selecting immediate intrauterine device (IUD) insertion, depot-medroxyprogesterone acetate (DMPA), or Norplant may begin their contraceptive this day as well.

• Postoperative appointments are usually 1-3 weeks after the procedure and are important to ensure timely involution, confirm the pregnancy termination has been completed, evaluate the patient for medical complications, offer continuing contraceptive care, and evaluate psychological status.

• Postoperatively, patients should be given instructions to contact their providers if they have severe pain, run a fever of 100.4ºF or higher, or soak through more than 4-5 pads per hour or more than 12 pads in 24 hours. The first 24 hours, a nonaspirin analgesic, such as acetaminophen, is recommended, and after that time, patients can switch to a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen.

• Provide patients with emergency contact numbers and instructions regarding where to present if they have an emergency and cannot reach the provider.

• Patients may bleed very little, if at all, if they were very early in gestation, but the most common bleeding pattern is to have bleeding the day of the procedure, then not much until the fifth postoperative day when heavier cramping and clotting occurs.

• Patients should not use tampons for 5 days and should not have intercourse until bleeding has stopped for a week or they have been cleared by their provider at their postoperative visit.

• With antibiotic use as prophylaxis, postabortion infection rates in most population groups should be less than 1-2%. Antibiotic use for the procedure usually is limited to the day of the procedure or a 2-3 day course. The antibiotics used are typically broad spectrum, and most centers use doxycycline 100 mg bid, with erythromycin for those who are allergic. If bacterial vaginosis is discovered, then the use of Flagyl 500 mg bid or Cleocin 300 mg bid PO is selected. Some providers with caseloads of patients who come from far distances and are difficult to locate postoperatively may select to administer longer antibiotic courses to cover the event of a positive CT or GC test coming back after the patient has left the facility and either cannot be or does not want to be contacted.

• Most oral contraceptive pills can be started the day of the procedure or the following Sunday. IUDs can be inserted that day or with the next menstrual period. DMPA shots can be given that day or up to 5 days later.

• Patients who have had their pregnancies terminated need a postoperative evaluation in 1-3 weeks. Women should be offered a contact number for any questions, and episodes of unusual pain or bleeding should be cause for an early postoperative visit.

• Uterine perforation: If the patient had a fundal perforation with no suction applied, then observation for a few hours and evaluation of hemoglobin levels is standard of care.

• Evaluation of acute abdominal pain postabortion: Suspect acute hematometra, retained products of conception, pelvic infection, or perforation with or without bowel involvement.

In/Out Patient Meds:

• Antibiotic therapy

• Uterotonics

• Analgesia

• Antiemetics

• Antianxiolytics

• Oral contraceptives

• Long-term steroid contraception

Deterrence/Prevention:

• Effective contraception is the only reasonable strategy toward abortion prevention. Since the introduction of the long-acting steroid contraceptives, abortion rates in the United States have steadily declined.

Complications:

• Uterine hemorrhage
  • Hemorrhage has been defined in a variety of ways; the need for transfusion is exceedingly rare. If uterine hemorrhage rates include hemorrhage immediately postabortion, uterine atony rates of hemorrhage are as low as 5%. Initial hemorrhage should be evaluated by ensuring complete uterine evacuation.

  • The next steps are typically medical: the use of intramuscular Methergine 0.2 mg, the use of intravenous Pitocin drips with 10-20 mIU/L running at 100-200 cc. Hemabate also is helpful.

  • In the past, uterine packing has been used, but this can be accomplished effectively with the intrauterine inflation of a Foley balloon. Five cc balloons can be inflated with 30 cc, or 30 cc balloons can be inflated with up to almost 100 cc of sterile saline. The inflation should correlate with uterine size.

  • Uterine artery embolization can be used if placenta accreta is encountered, but very few of these procedures have been performed, and statistical success rates are impossible to evaluate.

• Uterine perforation
  • Perforation rates have been estimated to occur in 1 per 250 cases. They usually are fundal and recognized by the provider at the time of the procedure. In a study by Pridmore of 13,907 women who underwent outpatient termination of pregnancy, the perforation rate was 0.05%, and in the second trimester, procedures from 13-20 weeks, the perforation rate was 0.32%.

  • Risk factors for perforation are previous terminations of pregnancy, lower segment cesarean sections, and loop electrosurgical excision procedures (LEEPs) of the cervix. The common denominator is thought to be scarring of the internal cervical os.

  • Fundal perforations only require observation. If the extent of the perforation cannot be determined, if the patient is medically unstable, if the suction was applied at the time of the perforation, or if bowel or fat content was obtained by forceps at the time of a perforation, surgical evaluation of the patient is necessary. The surgical evaluation may be performed by an experienced laparoscopist or by laparotomy.

• Retained products of conception
  • Evaluation of the obtained products of conception at the time of abortion and postabortion uterine scanning have reduced the retained products of conception rate to less than 1% of cases, and in one series reported by Hakim, Tovell, and Burnhill of 170,000 cases, only 0.5% incidence occurred in the first trimester. In cases of second trimester abortions, retained tissue rates are even lower with rates of 0.2% according to Peterson and 0.5% according to Kafrissen et al.

  • Cases of delayed bleeding even after a normal cycle have been reported. Dilatation and curettage or hysteroscopy are necessary if bleeding is brisker or if the amount of tissue is determined by sonography to warrant more extensive procedures. Endometrial color flow can be helpful in determining retained tissue.

• Endometritis and pelvic inflammatory disease
  • Infections postabortion are rare, occurring in fewer than 1% of cases. These usually are due to preexisting infections, such as bacterial vaginosis, cervicitis or salpingitis, or a failure of antibiotic prophylaxis.

  • The usual criteria for the diagnosis of pelvic inflammatory disease (PID) should be used. A thorough discussion of PID and the criteria for diagnosis can be found at http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00031002.htm.

• Coexistent ectopic pregnancy
  • Residual positive HCG titers are not uncommon, and clinicians need to be vigilant in their evaluation of persistent positive pregnancy tests in order to avoid missing an ectopic pregnancy.

  • Pelvic ultrasonography is the most helpful tool. Presence of significant tenderness on postoperative exam, a history of continued pain, and increasing or plateauing HCG titers should make a clinician suspicious. Coexistent interactive and extrauterine pregnancies are observed only in extremely rare cases.

• Asherman syndrome
  • Postabortion uterine synechiae (or adhesions) that can obliterate part or all of the endometrial cavity have been reported. This is thought to be more likely secondary to endometritis than the instrumentation of the uterus, but sharp curetting after the abortion procedure should be avoided to avoid denuding the basal layer of the endometrium.

  • The diagnosis is made by hysteroscopy or hysterosalpingogram in a patient who presents with postabortion amenorrhea.

• Delayed sequelae

• Few long-term sequelae of abortions have been documented. Although a syndrome of posttraumatic stress has been reported, the literature has not been able to separate the stressors of the patient's social situation that lead to the abortion from the abortion procedure itself.

• Initial studies seemed to indicate a greater risk of elective termination than that of term birth. Most of these data have been refuted. In the Iowa Women's Health Study, women aged 55-64 years had their health records of the state linked with the national Cancer Institute's Surveillance, Epidemiology and End Results Program (SEER). For information on the SEER program. Only 1.8% of the women in this study reported induced abortion, which is lower than other age groups will be as they reach that age, but the relative risk of breast cancer for those with prior induced abortion was 1.1%. These results must be reevaluated over time.

• One recent article reported a slightly greater incidence of adenomyosis postabortion. A study by Zhou of 15,727 women who had induced abortions compared with 46,026 women who did not have induced abortions showed an increased risk in preterm and postterm pregnancy after induced abortion. Another study by Hendricks showed that both induced abortion and prior cesarean section increased the risk of placenta previa. In women with 3 prior cesarean sections, the relative risk was 2.4 and the risk of having 2 or more previous abortions was 2.1.

• In another study by Eras, abortion was suggested as a protective factor against the development of preeclampsia in a subsequent pregnancy in women with no prior deliveries.

• Psychologic consequences of abortion
  • Generally, the psychological health of the abortion patient parallels her psychologic health prior to seeking an abortion. If the woman needed to have the abortion in secrecy, then long-term psychologic sequelae, such as intrusive thoughts, are more common.

  • Many studies actually have demonstrated improved psychological well-being after abortion. For the studies that have shown this, the improvement in psychological health is suspected to be more reflective of the patient dealing with the social issues that led her to select abortion to begin with.

  • Sometimes, confusion over normal emotions, such as sadness and grief versus psychological illnesses (eg, depression), seems to occur. The most common feeling experienced after an abortion is that of relief and confidence in the decision. Few women may experience feelings of grief and guilt postabortion, and these feelings usually pass within days to weeks in most cases and do not lead to psychological sequelae. One study demonstrated that the risk for serious psychiatric illness postabortion was 1%, whereas with live birth it was 10%. Few studies on these data exist, partly because studies performed earlier gave no indication for psychiatric sequelae so no new findings have been researched. Considering that over 1.5 million abortions are performed in the United States each year, if an epidemic of psychiatric sequelae due to the procedure occurred, it would be observed by now.

  • Many confounding factors are involved in a women's emotional status during the time of her abortion. Relationships, religion, age, social support, and previous psychological stability all play a part.

  • An entire new set of circumstances and feelings exist in cases of rape and incest. These are often psychologically complex situations and unique to each case.

• Providers can help women through abortions by presenting options and explaining the procedures. Counseling with a trained professional occurs before the abortion. This is a good time to identify factors that might lead to a patient having difficult feelings after the abortion. Some factors are low self-esteem, preexisting or past psychological illness, lack of emotional support, and past childhood sexual abuse. The counselor can then confront these issues before the procedure and help the patient assess specific needs and improve coping strategies.

Prognosis:

• Fertility is not impaired. Prognosis is excellent.

Patient Education:

• Give patients information about abortion and how to care for themselves postabortion.

• Educate patients about birth control options, and discuss when to start birth control postabortion.

• Roe versus Wade
  • An important early decision by the Supreme Court constitutionally establishing a woman’s right to privacy was Griswold versus Connecticut in 1965.

  • In the early 1970s, there was overwhelming political support to legalize abortion, and abortion rights activists specifically sought a plaintiff so that a legal challenge to abortions could be argued in court. The plaintiff, Norma McCorvey, was the “Jane Roe” for whom the decision is named. The CDC defines an induced abortion as “a procedure intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age.”

• Eroding abortion rights
  • Although the fundamental right to have an abortion has remained intact by basic statute, poor women have had their rights eroded by the Hyde amendment in 1976 prohibiting the use of federal funds for abortions except in the case of maternal life endangerment. This, in conjunction with a rise in the takeover of hospitals in some regions by religious organizations opposed to abortion as well as contraception, has restricted access to abortion. Almost one third of publicly funded recipients are prevented from having a termination by lack of access to care. Public controversy has raged on the specific question of whether individuals or institutions should be allowed to refuse legal care. Although 45 states have enacted laws allowing such refusal, only 5 also have enacted laws that require the provider to notify patients of their refusal. These provisions extend to contraceptive and sterilization services.

  • The fetus can survive extrauterine life at term and with life support in the mid second trimester. No definitive point exists at which the fetus cannot survive, nor does a medically agreed upon, a legislatively agreed upon, or a religiously agreed upon point at which viability exists. Fetuses generally are considered viable after 27 weeks of pregnancy and not viable at less than 20 weeks of pregnancy.

  • In a 1989 decision called Webster versus Reproductive Health Services, the Court upheld the state’s right to determine viability testing after 20 weeks of gestation, and in the legal preamble, the wording states that life begins at conception. Other laws cover similar legal concepts. In Planned Parenthood versus Casey, some fetuses were recognized to never attain viability (anencephalics), and in Colautti versus Franklin, the provisions are even broader, recognizing that physician judgment may be the most important.

  • For a listing of abortion-related historical facts see the Hope Clinic for Women, History of Abortion.

• Late-term abortions

• Although only 2% of the population verbalizes opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, another divisive factor has crept into the debate. Abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.

• By 1998, 28 states had passed bans on this procedure, referred to in the lay press as a partial-birth abortion, which is the medical procedure intact dilatation and extraction. The descriptive language in the US Criminal Code, if passed, would make it illegal to “deliberately and intentionally deliver into the vagina a living fetus, or a substantial portion thereof, for the purpose of performing a procedure the physician knows will kill the fetus and kills the fetus.”

• President Clinton has twice vetoed the federal Partial-Birth Abortion Ban Act on the grounds that the language is unconstitutionally vague and provides physicians no clear direction in how to apply the law. Oddly, physicians have been successfully sued for failure to refer for late-term abortions in cases of fetal abnormalities. The rationale for continued need for late abortions has been argued thoroughly by David Grimes in The continuing need for late abortions.

• Since the time of Roe versus Wade, physicians, patients, and the Supreme Court have repeatedly reaffirmed that the determination about medical need, the choice of a procedure, and viability is best left as a medical decision, not one for the legislature.

• Parental consent

• Most young adolescents have parental or family involvement in their decision to have an abortion. Adolescents who are older, especially those living independently, often do not. In spite of ample scientific evidence that the majority of teens seek parental involvement and widespread legal concern that individuals who do not seek parental involvement may be at risk physically or emotionally, a barrage of legislation mandates that all minors seek parental consents or that the parents be notified in advance of a minor child having an abortion.

• The laws that have enabled this to occur legally are backed in the Supreme Court. By 1999, 38 states had such laws, and 29 states enforce their laws. Currently only Connecticut, Maine, and the District of Columbia have laws that affirm the rights of a minor to seek her own abortion. For a summary of laws as of September of 2000 see Minors' Right to Consent to Health Care and to Make Other Important Decisions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents that may travel hundreds of miles to seek an abortion.

• Patient rights bills have been developed by a variety of groups including the Consumers’ Bill of Rights and Responsibilities that has been developed by a presidential task force. These bills specifically state that patients have a right to access knowledge, and that providers have a right to discuss care they think is medically appropriate regardless of the source of that care.

• Mandatory waiting periods

• Mandatory waiting periods mandate by law that the woman seeking to terminate a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives.

• In spite of the fact that these laws typically only mandate a short 24-hour waiting period, they have the effect of increasing the percentage of second trimester abortions in states with these laws.

Special Concerns:

• The abortion debate

• Advances in neonatal medicine with improved fetal survival very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on beginning of life.

• Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments has kept the debate both vocal and contentious. These therapies may be indicated in the treatment of diabetes, Parkinson disease, kidney disease, and cartilage diseases, among others.

• Current national regulations prohibit most fetal tissue research, but the National Institute of Health (NIH) revealed late in the year 2000 that it will allow stem cell research.

• Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface.

• Provider issues

• Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (family practitioners, nurses) can be taught to perform abortions safely. Physicians generally are receptive to the concept of legal abortions being available in the United States. Epidemiologic research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.

• Keeping abortions safe, legal, and rare are the goals of abortion providers. For information from physicians regarding these goals, see Physicians for Reproductive Choice and Health.

• As providers have decreased in number, women are traveling farther to obtain abortions, presenting later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.

• Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.

REFERENCES