Abortion (Termination Of Pregnancy)
What Is It?
Abortion (also called elective abortion, induced abortion, termination of pregnancy and therapeutic abortion) is the removal of “pregnancy tissue,” products of conception or the fetus and placenta (afterbirth) from the uterus. The terms fetus and placenta or afterbirth usually are used after eight weeks of pregnancy, while the other terms describe tissue produced by the union of an egg and sperm before eight weeks. Each year approximately 1.3 million women in the United States choose to end a pregnancy.
What It’s Used For
In the United States, abortion is used most often to end an unplanned pregnancy. Unplanned pregnancies occur when birth control is not used or is used incorrectly. Abortion is also used to end a pregnancy when testing reveals that the fetus is abnormal. Therapeutic abortion refers to an abortion recommended when the mother’s health is at risk.
Roughly one-half of all abortions are done during the first eight weeks of pregnancy; 88 percent during the first 12 weeks of pregnancy.
Your doctor will ask about your medical history and will examine you. Even if you used a home pregnancy test, another pregnancy test often is needed to confirm that you are pregnant. In some cases, you will need an ultrasound to determine how many weeks into the pregnancy you are and the size of the fetus, and to make sure the pregnancy is not ectopic (tubal), which means it is growing outside of the uterus.
A blood test will be done to determine your blood type and whether you are Rh positive or negative. The Rh protein is made by the red blood cells of most women. They are considered Rh positive. Some women have red blood cells that do not produce Rh protein. They are considered Rh negative. Pregnant women who have Rh-negative blood are at risk of reacting against fetal blood that is Rh positive. Such a reaction can harm future pregnancies, so Rh-negative women usually receive an injection of Rh immunoglobulin (RhIg) to prevent Rh-related problems after miscarriage or abortion.
How It’s Done
Doctors can use medications, surgery or a combination of both to end a pregnancy. The method depends on how far along in the pregnancy you are, your medical history and your preference. Abortions during early pregnancy — before eight to nine weeks — can be done safely with medications. Abortions between nine and 14 weeks usually are done surgically, although medications may be used to help soften and open the cervix. After 14 weeks, abortion can be done by using only labor-inducing medications that cause uterine contractions, or by using these medicines in combination with surgery.
Abortions done with medication, called medical abortions are done within 49 days (nine weeks) from the first day of the last menstrual period. Medications used to induce abortion early in pregnancy include:
- Mifepristone (Mifeprex) — Known as RU-486, mifepristone is taken orally as a pill, and was approved for use in the United States in 2000. This drug counters the effect of progesterone, a hormone necessary for pregnancy. More than 3 million women in Europe and China have received the drug to end a pregnancy.
Side effects include nausea, vomiting, vaginal bleeding and pelvic pain. These symptoms usually can be treated with medications. In rare instances, there may be heavy bleeding. In that case, you may be admitted to a hospital and given blood transfusions.
Mifepristone’s effectiveness is increased when another medication, such as misoprostol (Cytotec), is taken 48 hours later. It causes the uterus to contract. Between 92 percent and 97 percent of women who receive mifepristone in combination with, or followed by, misoprostol will have a completed abortion within two weeks.
- Misoprostol (Cytotec) — Misoprostol, alone or following mifepristone, can induce abortion. Misoprostol is a prostaglandin-like drug that causes the uterus to contract. One form can be taken by mouth. The other is inserted into the vagina. The vaginal form is less likely to cause side effects and is as effective as the oral form. Side effects include diarrhea, nausea, vomiting and vaginal bleeding.
- Methotrexate — Methotrexate is used less often since the U.S. Food and Drug Administration approved mifepristone. However, methotrexate may be used in women who are allergic to mifepristone, or when mifepristone is not available. Methotrexate usually is given by injection into a muscle. Between 68 percent and 81 percent of pregnancies abort within two weeks and 89 percent to 91 percent after 45 days. Methotrexate also is the medication most often used to treat ectopic pregnancies.
In rare instances when a pregnancy continues after the use of these medications, there is a risk that the baby will be born deformed. The risk is greater with the use of misoprostol. If the pregnancy tissue does not completely pass within two weeks of a medical abortion, or if a woman bleeds heavily, then a surgical procedure may be needed to complete the abortion. Approximately 2 percent to 3 percent of women who have a medical abortion will need to have a surgical procedure, usually suction dilation and curettage (D & C), also called vacuum aspiration.
A woman should not have a medical abortion if she:
- Is more than 49 days pregnant
- Has bleeding problems or is taking blood-thinning medication
- Has chronic adrenal failure or is taking certain steroid medications
- Is suspected of having or is diagnosed with an ectopic pregnancy
- Is allergic to these medications
- Cannot attend the medical visits necessary to ensure the abortion is completed
- Does not have access to emergency care
- Has uncontrolled seizure disorder (for misoprostol)
- Has acute inflammatory bowel disease (for misoprostol)
- Menstrual aspiration — This procedure, also called menstrual extraction or manual vacuum aspiration, is done within one to three weeks after a missed menstrual period. This method can also be used to remove the remaining tissue of an incomplete miscarriage (also called a spontaneous abortion). A doctor inserts a small, flexible tube into the uterus through the cervix, and uses a handheld syringe to suction out the pregnancy material from inside the womb. Local anesthesia is usually applied to the cervix to decrease the pain of dilating the cervix. (Local anesthesia numbs only the area injected and you remain conscious.) Medication given intravenously (into a vein) can be used to decrease anxiety and the body’s general response to pain. Menstrual aspiration lasts about 15 minutes or less.
- Suction or aspiration abortion — Sometimes called a suction D & C (for dilation and curettage), this procedure can be done up to 13 weeks after the first day of the last menstrual period. Suction D & C is the procedure most commonly used to end a pregnancy. The cervix is dilated (widened) and a rigid hollow tube is inserted into the uterus. An electric pump sucks out the contents of the uterus. The process takes about 15 minutes. Local anesthesia is usually applied to the cervix to minimize the pain of dilating the cervix. Medication given intravenously (into a vein) may be helpful to decrease anxiety and relieve pain.
- Dilation and curettage (D & C) — In a dilation and curettage, the cervix is dilated and instruments with a sharp edge, known as curettes, are used to remove the pregnancy tissue. Suction is often used to ensure all the contents of the uterus are removed. The earlier in pregnancy this procedure is done, the less the cervix has to be dilated, which makes the procedure easier and safer.
- Dilation and evacuation (D & E) — This is the most common procedure for ending a pregnancy between 14 and 21 weeks. It is similar to a suction D & C but with larger instruments. The cervix has to be dilated or stretched open to a size larger than required for a D & C. Suction is used along with forceps or other special instruments to ensure all the pregnancy tissue is removed. The procedure takes more time than other abortion procedures.
- Abdominal hysterotomy — This is a major operation to remove the fetus from the uterus through an incision in the abdomen. This is rare but may be necessary if a D & E cannot be done. Anesthesia will be given to make you unconscious for this surgery.
Induction of labor
After 14 weeks of pregnancy, abortion can be done by giving medication that causes the woman to go into labor and deliver the fetus and the placenta. The procedure usually requires hospitalization for more than a day because it involves a labor and delivery. Sometimes dilation and evacuation is necessary to completely remove the placenta. Starting or inducing labor can be accomplished in one of three ways:
- Invasive — Injecting labor-inducing medications by passing a needle through the abdomen and into the uterus, usually within the amniotic sac
- Noninvasive — Giving labor-inducing medications by mouth, intravenously (into a vein), through an injection into a muscle, or inserted in the vagina
- A combination of invasive and noninvasive approaches — Usually necessary when abortion is done late in the second trimester, before 24 weeks
A medical abortion of an early pregnancy usually requires three or more visits to get your abortion medication and make sure all the pregnancy tissue has passed. Bleeding related to the abortion may last up to two weeks.
You usually can resume most daily activities within hours after a surgical abortion done with local anesthesia between nine and 14 weeks, but no sedatives were used. If you received sedatives or were unconscious, as with general anesthesia, then you should not drive or use dangerous machinery for at least 24 hours. In either case, you should avoid sexual activity for two weeks to prevent infection, and allow the cervix and uterus to return to normal shape and size. Most women are advised to follow up at the doctor’s office about two weeks after the procedure.
You usually can resume most daily activities a few days to a couple of weeks after a late second trimester abortion, depending on how far along you were in your pregnancy and whether there were complications. Sexual activity may not be advisable for two to six weeks after the procedure. In general, a follow-up visit with the doctor is advisable about two weeks after the procedure. More specific advice on resuming daily activities and working depends on the individual’s circumstances.
Cramps can be treated with acetaminophen (Tylenol) or ibuprofen (Advil and others). Cramping may be worse after a late second-trimester abortion. After a medical or surgical abortion, you may be told not to use tampons or douches or have sex for at least two weeks. This will help to decrease the risk of an infection of the uterus. Vaginal spotting or bleeding is common for a few days up to one to two weeks after a surgical abortion, depending on how far along the pregnancy was at the time of the abortion.
The risks of having a medical abortion include infection, bleeding, and incomplete abortion, meaning some of the pregnancy tissue remains. Generally, these problems are rare and can be treated. An incomplete abortion is handled by repeating the dose of medication to end the pregnancy or doing a suction D & C. An infection can be treated with antibiotics. Excessive bleeding is treated with medications and possibly dilation and curettage. Rarely, a blood transfusion may be necessary if bleeding has been unusually heavy.
Risks from surgical abortion are quite low. The main risks of D & C and D & E are continued bleeding, infection of the uterus (endometritis), incomplete removal of pregnancy tissue, and poking a hole in the womb (perforation of the uterus) during the surgical procedure. A second surgical procedure may be required to remove tissue that was not removed during the first procedure, or to repair a perforated uterus.
Infertility may result when surgical abortion leads to endometritis, or is complicated by heavy bleeding, perforation or incomplete removal of pregnancy tissue, otherwise infertility rarely occurs after an uncomplicated abortion.
When To Call A Professional
Contact your doctor for any of the following problems:
- A fever of 100 degrees Fahrenheit or higher
- Bleeding heavier than a normal menstrual period, soaking pads at a rate of one per hour or more, or passing large clots
- Severe abdominal or back pain
- Unusual or foul-smelling vaginal discharge
- No bleeding within 24 hours after the medical abortion of an early pregnancy
by Mamikon Bozoyan, M.D.
All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.