RSS Feeds
Induced Abortion: An Overview for Internists
- David A. Grimes, MD; and
- Mitchell D. Creinin, MD
- From University of North Carolina School of Medicine, Chapel Hill, North Carolina, and University of Pittsburgh School of Medicine, Magee-Womens Research Institute, Pittsburgh, Pennsylvania.
Abstract
Internists care for many women who have had abortions and many who will seek abortions in the future. Each year, about 2% of all women of reproductive age have an abortion. Women having abortions tend to be young, white, unmarried, and early in pregnancy. Most abortions are done by suction curettage under local anesthesia in a freestanding clinic. However, medical abortion is growing in popularity as a nonsurgical alternative. The regimen approved by the U.S. Food and Drug Administration specifies mifepristone, 600 mg orally, followed 2 days later by misoprostol, 400 µg orally (within 49 days from last menses). Recent studies have recommended alternative approaches, such as mifepristone, 200 mg orally, followed in 1 to 3 days by misoprostol, 800 µg vaginally (up to 63 days). Medical abortion can be provided by a broader variety of physicians than can surgical abortion. The overall case-fatality rate for abortion is less than 1 death per 100 000 procedures. Infection, hemorrhage, acute hematometra, and retained tissue are among the more common complications. Referral back to the original abortion provider for management is advisable. Overall, induced abortion does not lead to late sequelae, either medical or psychiatric. Of importance, no link exists between induced abortion and later breast cancer. For physicians who are asked to help with a referral, the National Abortion Federation and Planned Parenthood Federation of America have helpful Web sites and networks of high-quality clinics. The cost of abortion (currently about $372 at 10 weeks) has decreased in recent decades. Provision of ongoing contraception and encouragement of emergency contraception can reduce unintended pregnancies and the need for abortion.
Key Summary Points
Each year, about 2% of all women of reproductive age in the United States have an induced abortion.
Most abortions are performed by vacuum aspiration under local anesthesia in freestanding clinics.
Use of medical abortion with mifepristone plus misoprostol, methotrexate plus misoprostol, or misoprostol alone is growing in early pregnancy.
Abortion remains one of the safest procedures in contemporary practice, with a case-fatality rate less than 1 death per 100 000 procedures.
Abortion does not lead to an increased risk for breast cancer or other late psychiatric or medical sequelae.
The National Abortion Federation and Planned Parenthood Federation of America have helpful Web sites and networks of high-quality clinics.
Most internists' practices include large numbers of patients who have had or will seek induced abortion. Although abortion rates are declining, were they to remain stable, an estimated 43% of all U.S. women would have had one or more induced abortions during their reproductive years (1). More than 30 million U.S. women now share this experience.
Because surgical abortion is one of the most common operations in contemporary practice and new technologies have emerged over the past decade, this article will provide a primer for internists. We describe the numbers and characteristics of women having abortions, review the methods used, summarize safety data, explain how internists can help patients with referrals to abortion providers if requested, and describe costs. We focus on early induced abortion, which dominates practice in the United States. Our sources were textbooks, review articles, and a search through PubMed using the Medical Subject Heading terms abortion, induced; abortion, legal; and abortion, therapeutic.
What Is an Abortion?
Abortion is the removal of a fetus or embryo from the uterus before the stage of viability, further defined as “20 weeks' gestation or fetal weight < 500 g” (2). The latter descriptors are misleading, however, because fetal viability has not been reported at 20 weeks and weight alone is a poor predictor of viability. The terminology of timing is also confusing. The notion of pregnancy “trimesters” was adopted by the U.S. Supreme Court in the Roe v. Wade decision of 1973, which legalized abortion nationwide. Regrettably, this obstetrical convention has no basis in biology, and the distinction between first- and second-trimester abortion remains blurred after 3 decades. The practical importance is that states may regulate second-trimester abortions, for example, specifying that abortions must take place in a hospital. However, pregnancy should be considered a continuum, with no clear demarcations once embryogenesis is complete.
Two terms describe abortion frequency: the annual rate (number of abortions per women of reproductive age) and ratio (number of abortions per live births). The abortion rate in 1999 was 17 abortions per 1000 women age 15 to 44 years; stated alternatively, about 2% of all women of reproductive age have an abortion each year. The corresponding abortion ratio was 256 abortions per 1000 live births, about 1 induced abortion for every 4 live births (3).
Who Has an Abortion?
Women who have abortions tend to be young, white, unmarried, and early in pregnancy (Table 1) (3). In 1999, more than half of abortions (58%) were obtained at 8 or fewer weeks of gestation (counted from the first day of the last menstrual period), and 88% were performed before 13 weeks. Suction curettage (also called vacuum aspiration) accounted for nearly all abortions.
Several important demographic and medical trends are evident over the past 3 decades (Table 1). The proportion of teenage patients having abortions has declined, as has the proportion of married women. Women have been obtaining abortions at progressively earlier gestational ages and by suction, rather than sharp, curettage (4). As of 1999, over half of all women having abortions were mothers of one or more children. A nationwide survey by the Alan Guttmacher Institute indicated that in 2000 and 2001, most women older than 17 years of age reported a religious affiliation: 43% Protestant, 27% Catholic, 8% other, and 22% no religious affiliation (5). Forty-six percent of women had not used a contraceptive method in the month in which they conceived; inconsistent use of contraceptive method was the main cause of pregnancy among those using contraception (6).
How Is a First-Trimester Abortion Provided?
When women inquire about abortion, physicians should review all the options for the pregnancy as part of informed consent. These include carrying the pregnancy to delivery and keeping the baby, delivering the baby and giving it up for adoption, or abortion. If abortion is chosen, counseling can then focus on the procedures available; this discussion needs to include the efficacy, benefits, risks, and side effects of surgical abortion and, for women at 9 or fewer weeks of gestation, the alternative of medical abortion. The National Abortion Federation (http://www.prochoice.org) and Planned Parenthood Federation of America (http://www.ppfa.org) Web sites provide information about pregnancy options and providers. Physicians need to understand all local and federal regulations related to abortion provision.
Abortion can be accomplished by surgical or medical techniques. Surgical abortion entails evacuation of the products of conception through the cervix. The phrase “medical” abortion refers to early abortion effected by drugs (usually before 9 weeks of gestation) (7).
Surgical Abortion
Accurate determination of the duration of the pregnancy is an important prerequisite to abortion; as is often the case in surgery, surprises are unwelcome. Therefore, most National Abortion Federation clinics surveyed (66%) use ultrasonography to confirm gestational age before surgical abortion (8).
Suction curettage dominates practice in the United States. This technique evacuates the uterine contents with negative pressure; the source of vacuum is commonly an electrical pump or a hand-held syringe. The process involves cervical dilation to a diameter less than 12 mm, followed by evacuation of the uterine contents. Physicians have traditionally inserted a series of progressively larger metal or plastic dilators for dilation. In recent years, use of vaginal or oral misoprostol, a prostaglandin E1 derivative, has grown in popularity. Administration of misoprostol, 400 µg (2 tablets) vaginally, for 2 to 3 hours before the abortion softens and opens the cervix (9), although whether this decreases complication rates or improves patient acceptability is unknown.
After the cervix is dilated, a plastic cannula is introduced into the uterine cavity and connected to the suction source to perform the abortion. Cannulas range in diameter from 4 to 14 mm. Suction curettage is safer, faster, and more comfortable than its predecessor, sharp curettage (also termed D & C for dilation and curettage). Procedure time is usually less than 5 minutes.
Local anesthesia is the most common approach to pain control. In a recent survey of providers, 58% used paracervical block with or without oral premedication, 32% combined paracervical block with intravenous sedation, and 10% used general anesthesia (8). Local anesthesia is both safer and less expensive than general anesthesia, although pain relief is not complete. With local anesthesia, most women have discomfort similar to bad menstrual cramps during the operation; this resolves soon after the operation is finished. Most women are comfortable at the time of discharge.
After the abortion, the woman is monitored in a recovery room for about 30 minutes. Before discharge, she receives information about warning signs of common complications, and most women leave the clinic with their chosen method of contraception. Standard practice is for the physician or a designee to inspect the aspirated tissue to confirm successful completion of the abortion and to exclude an unsuspected ectopic pregnancy. Formal pathologic examination of the products of conception is unnecessary (10). Women who are Rh negative receive Rh immunoglobulin. Many women resume their usual activities the same day as the abortion, although some prefer to wait another day before returning to routine daily activity.
A follow-up visit is usually scheduled in 2 or 3 weeks, but evidence supporting the benefit of this visit is lacking. Moreover, only about half of women opt to return. The principal use of the follow-up visit may be management of contraception. If an internist sees an asymptomatic woman for follow-up after abortion, a pelvic examination is typically performed but is unnecessary. Likewise, no laboratory tests are indicated. Most important, the patient should be asked how she is doing with her chosen contraceptive.
Medical Abortion
The most commonly used medical abortion regimen throughout the world is mifepristone followed by a prostaglandin analogue, usually misoprostol. However, in areas without access to mifepristone, methotrexate and misoprostol or misoprostol alone are acceptable alternatives. Mifepristone regimens result in higher rates of complete abortion and cause expulsion more rapidly than those using methotrexate and misoprostol and misoprostol alone (11, 12).
Mifepristone, a derivative of the progestin norethindrone, binds strongly to the progesterone receptor without activation, thereby acting as an “antiprogestin.” Mifepristone results in separation of the trophoblast from the endometrial wall; it also increases endogenous prostaglandin release and sensitizes the myometrium to exogenous prostaglandins. In addition, mifepristone softens the cervix to allow expulsion. Initial studies of mifepristone attempted to find the optimal regimen to achieve acceptable rates of expulsion. However, not until investigators began following mifepristone with small doses of a prostaglandin analogue did the efficacy approach 100% (13).
Misoprostol is the prostaglandin analogue most commonly used with mifepristone because of its safety, low cost, and stability at room temperatures. Misoprostol can also be placed in the vagina, which leads to slower absorption and a lower peak serum level (14). However, the area under the curve following vaginal misoprostol is greater (Figure 1). In addition, vaginal administration may have direct cervical and uterine effects. Clinically, vaginal administration of misoprostol results in greater efficacy and lower rates of continuing pregnancy (15, 16).
The mifepristone and prostaglandin analogue regimen for medical abortion, approved by the U.S. Food and Drug Administration (FDA), involves a single 600-mg oral dose of mifepristone followed approximately 48 hours later by misoprostol, 400 µg orally, in women up to 49 days of gestation. This results in complete abortion in 92% to 99% of women (11, 17, 18). Between 2% and 5% of women will abort before misoprostol administration (16-18).
Gestational age and location of the pregnancy are confirmed before mifepristone administration. In the United States, vaginal ultrasonography is commonly performed for these purposes. The patient then takes the mifepristone under observation by a health care provider. The FDA guidelines for mifepristone regimens for medical abortion stipulate that the patient should return in 2 days for an evaluation before misoprostol administration. Once she swallows the misoprostol, the patient has the option of staying in the office for observation or returning home. Some clinicians administer additional doses of misoprostol if abortion has not occurred. A follow-up examination is performed 2 weeks later to confirm expulsion, which is based on the patient's history of events after misoprostol use and pelvic examination. Suction curettage is performed if complete expulsion has not occurred.
The FDA-approved dose of mifepristone is excessive. A 200-mg dose is as effective as the 600-mg dose when combined with a prostaglandin analogue (18-21). Because mifepristone is the more expensive of the medications, lower-dose regimens are more economical.
Women can administer misoprostol themselves, eliminating a trip back to the provider (15, 21-24). In the 3 largest trials using mifepristone, 200 mg, and misoprostol, 800 µg vaginally (21, 22, 24), 90% of women in all studies found home use of misoprostol acceptable regardless of previous abortion experience (22), gestational age (21), or time between mifepristone and misoprostol use (24). Four (0.1%) participants in 2 studies totaling almost 4500 women experienced adverse events soon after misoprostol administration (21, 22). Only one of these events could have been avoided with observation of the woman in an office or clinic.
Misoprostol can be used sooner after mifepristone than the time interval recommended by the FDA. Regimens with a shorter interval between mifepristone and misoprostol administration, if effective, might reduce abortion times and increase acceptability (24). In addition, because approximately half of women bleed during the 48 hours after mifepristone is given (18, 22), administering the misoprostol sooner would decrease such an undesirable side effect. The standard regimen with an interval of only 6 to 8 hours is ineffective. However, Schaff and colleagues (15, 24) demonstrated in 2 multicenter, randomized trials that the regimen of mifepristone, 200 mg, followed between 24 and 72 hours later by misoprostol, 800 µg vaginally, is more effective than regimens with oral misoprostol.
Follow-up sooner than 2 weeks can accurately predict successful abortion when vaginal ultrasonography is routinely used to confirm expulsion (15, 21, 22, 24). Without ultrasonography, whether the patient or physician can accurately assess outcome in these situations is unknown. The main goal of the ultrasonography is to determine the presence or absence of the gestational sac. Harwood and colleagues (25) demonstrated that clot and debris are normally seen in the uterus when transvaginal ultrasonography is used after medical abortion; the thickness of the endometrial lining does not predict abortion success.
Current evidence supports use of regimens with mifepristone, 200 mg, followed 24 to 72 hours later by misoprostol, 800 µg (up to 63 days of gestation). The misoprostol can be administered by the patient at home at a convenient time. A follow-up evaluation can be performed by physical examination at 2 weeks or sooner if transvaginal ultrasonography is used to assess the uterine cavity.
Pain management typically includes use of ibuprofen or acetaminophen initially, with oral narcotics if necessary. The use of a nonsteroidal anti-inflammatory drug, such as ibuprofen, is not contraindicated and does not decrease the likelihood of abortion after administration of a prostaglandin analogue (26). Some clinics provide patients with a prescription for 20 plain codeine tablets with instructions to use 1 to 3 tablets as needed should the nonsteroidal anti-inflammatory drugs provide inadequate relief. Bleeding typically begins within 3 hours of misoprostol administration. Even though heavy bleeding is expected, patients are typically fine unless they are soaking 2 thick sanitary pads per hour for 2 consecutive hours (27). While intervention may not be necessary, consultation with the provider is advisable. Management at that point should reflect the patient's physical and emotional comfort and baseline hemoglobin level as well as whether the bleeding is slowing. Transportation time to emergency care, if necessary, should also be considered.
The duration of bleeding after a medical abortion using mifepristone varies among studies. Three studies, including 2 from France, found an average duration of bleeding of 9 days (16, 17, 28), with a range of 1 to 32 days (16, 17). However, the remainder of studies, including those from the United States, report a mean duration of bleeding of 14 to 17 days (22, 23, 29), with a range of 1 to 69 days (18, 23, 30). Davis and colleagues (31) followed women by using bleeding diaries to document bleeding patterns after administration of mifepristone and vaginal misoprostol. They reported bleeding for a mean of 14 days and spotting for a mean of 10 days. Overall, women had bleeding or spotting for an average of 24 days, longer than what is typically reported in efficacy studies. Twenty percent of women had bleeding or spotting that lasted more than 35 days.
Who Can Provide Medical Abortion?
Although gynecologists provide most surgical abortions, a broader variety of physicians may be able to provide medical abortions. These include family physicians, internists, and pediatricians. If the physician providing medical abortion does not have the skills or equipment for suction curettage, referral to other physicians can meet this occasional need. Physicians interested in obtaining mifepristone for medical abortion need to apply to the distributor (Danco Laboratories, New York, New York; http://www.earlyoptionpill.com). Training is available from the National Abortion Federation and other organizations.
How Safe Is Abortion?
Abortion is one of the safest procedures in contemporary practice. However, in some developing countries where safe, legal abortion is not available, 50 000 to 70 000 women die of unsafe abortion each year. Refinements in abortion technology, improvements in prevention and management of complications, and earlier abortions have all contributed to the impressive safety record (4) (Figure 2). The case-fatality rate from abortion today is less than 1 death per 100 000 abortions (32, 33). By comparison, the risk for death from anaphylaxis after parenteral administration of penicillin is about 2 per 100 000 events. The risk for complications is also low. In a recent large case series report, the risk for a complication requiring hospitalization was 0.7 per 1000 abortions; less serious complications occurred in 8 per 1000 abortions (34).
Both gestational age and abortion method influence abortion safety; in general, the earlier the abortion, the safer (Table 2). In terms of mortality risk, suction curettage early in pregnancy is the safest method that has been widely used. Delays in obtaining services, regardless of the cause, tend to increase both the risk and cost of abortions. Suction curettage is safer than sharp curettage; medical abortion also has low complication rates.
Infection, hemorrhage, acute hematometra, and retained tissue are among the more common complications (27). The low risk for infection is further reduced by administration of prophylactic antibiotics, a practice that is evidence-based (35) and widely used (8). A common antibiotic is doxycycline. Some surgeons send patients home with a short course of methylergonovine maleate to minimize uterine atony and bleeding, although evidence does not support any benefit of this treatment (36). The risk for hemorrhage severe enough to require blood transfusion is remote. Hematometra occurs when the uterine cavity fills with clotted and liquid blood in the postoperative period. Little or no vaginal bleeding accompanied by increasing lower abdominal cramping and an enlarged uterus suggest the diagnosis; prompt repeated aspiration of the uterus is both diagnostic and therapeutic. Repeated aspiration is also diagnostic and therapeutic for retained tissue, which causes continued or increasing bleeding after the procedure.
When primary care physicians are consulted by patients who are having complications after abortion, prompt referral back to the abortion provider is usually indicated. Some problems, such as hematometra, are uncommon outside of abortion practice, and gynecologists who do not perform abortions may have little experience with it. Moreover, clinics often provide care of complications at no additional charge to the woman.
Does Abortion Have Late Sequelae?
Extensive literature has documented the long-term safety of abortion. Induced abortion does not harm a woman's reproductive capacity. Premature birth, infertility, ectopic pregnancy, spontaneous abortion, and adverse pregnancy outcomes are not increased in frequency after abortion. The question of placenta previa is unsettled; some reports have found an increased risk for this abnormal placental attachment in later pregnancies, whereas others have not (37).
Induced abortion does not harm women's emotional health; for most women, it allows an overall improvement in quality of life (38, 39). Indeed, the most common reaction to abortion is a profound sense of relief. In some studies, abortion has been linked with improved psychological health because the abortion resolved an intense crisis in the woman's life. The alleged “postabortion trauma syndrome” does not exist (40).
Abortion does not increase a woman's risk for cancer. Flawed epidemiologic studies led to claims that abortion elevates a woman's risk for breast cancer in later life. However, recall bias among controls in case–control studies accounts for this association; large cohort studies from Scandinavia have found either no association or a protective effect of abortion (41). After review of the evidence, both the World Health Organization and the National Cancer Institute have concurred that no credible evidence supports a link between abortion and breast cancer.
Where Can a Woman Get an Abortion?
Most surgical abortions (93% in 2000) are provided in freestanding abortion clinics (42). Comparable data are unavailable for medical abortion. Clinics typically feature high-quality care in attractive surroundings. Most women receive services during a single visit. Because of economies of scale, clinics can provide services at lower costs than hospitals and most physicians' offices. Because clinics limit their clientele to healthy patients and because their surgeons are so experienced, complication rates are low (34). Paradoxically, abortions performed in hospitals have higher complication rates than do clinic abortions, in part because of higher-risk patients, residents in training, and less experienced surgeons than in freestanding clinics (43).
Access to abortion clinics remains a problem: Clinics cluster in metropolitan areas. About one third of women of reproductive age live in the 87% of U.S. counties without an abortion provider (42). Among the nation's 276 metropolitan areas, 86 have no provider. About a quarter of women have to travel 50 miles or more to reach a clinic (44); this geographic barrier hinders both service provision (45) and follow-up in case of complications.
How Do I Locate a Provider and Make a Referral?
Making an appropriate referral for an abortion is an important role for internists. Most urban areas have both clinics and private physicians who provide abortion services as part of general gynecologic practice. Clinics in the community tend to advertise in the yellow pages of the local telephone directory.
Referring physicians and their patients can identify reputable providers of abortion services through the National Abortion Federation, the professional association of abortion providers in the United States and Canada. The National Abortion Federation operates a hotline with factual information about abortion and pregnancy options in both English and Spanish. Information about member physicians and clinics can be obtained by calling 800-772-9100, and more information about the hotline is available at http://www.prochoice.org. In addition, many clinics of the Planned Parenthood Federation of America provide abortions. Its Web site (http://www.ppfa.org) enables users to find health centers near their ZIP code.
Clinicians and women need to be wary of fake clinics, biased counseling centers (numbering over 3000 nationwide), and misleading Web sites. Some telephone directory yellow pages include “crisis pregnancy counseling” facilities, which provide only directive counseling against abortion. This commonly includes misleading and deceptive messages (46). For example, the Web site http://www.prochoice.com, similar to the National Abortion Federation's Web address, lists “Developing breast cancer” as an abortion risk and warns that abortion “is a rip off with little concern for the patient, it's a business.” Links from this Web site connect to the Elliot Institute, an antiabortion organization.
When a referral is made, faxing to the clinic or providing the woman copies of relevant medical reports and tests, including her blood type or hemoglobin level, can expedite care. Background information is especially helpful regarding the need for administering antibiotics for cardiac prophylaxis, although few patients having an abortion fulfill American Heart Association criteria (47). If ultrasonography has been performed, a copy of the report should be provided as well.
How Much Does an Abortion Cost?
Unlike most other operations, the cost of abortion has dropped dramatically over the past 3 decades (48). The current charges are below market value for several reasons. First, the Hyde Amendment cut off federal payment of nearly all abortions for poor women in 1977, and clinics have intentionally tried to keep the price within reach of women of limited means. Seventeen states, including California and New York, currently use state funds to pay for medically necessary abortions; 33 states and the District of Columbia prohibit funding of medically necessary abortions, except in extraordinary cases (49). Nationwide, only a quarter of women receive services billed directly to public or private insurance (44). Second, competition between clinics in cities has kept costs low. In 2001 and 2002, the average self-paying woman was charged $372 for a surgical abortion at 10 weeks. Adjusted for the increase in the consumer price index over the past 3 decades, the charge should be several times higher (48). In general, clinics set medical and surgical abortion prices to be similar so as to eliminate financial reasons for women to choose between the methods.
Induced abortion represents secondary prevention of an unintended pregnancy. Primary prevention, through ongoing and emergency contraception, deserves more attention from all physicians. Contraception is especially important for women with serious illnesses, for whom unintended pregnancy may pose special risks. Provision of contraception and encouragement of emergency contraception, as needed, can further reduce the burden of suffering from unintended pregnancies nationwide.
Article and Author Information
-
Potential Financial Conflicts of Interest:Employment: D.A. Grimes, M.D. Creinin; Consultancies: M.D. Creinin (Danco Laboratories); Expert testimony: D.A. Grimes.
-
Requests for Single Reprints: David A. Grimes, MD, Department of Obstetrics and Gynecology, CB #7570, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7570.
-
Current Author Addresses: Dr. Grimes: Department of Obstetrics and Gynecology, CB #7570, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7570.
-
Dr. Creinin: Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA 15213-3108.
Related Clinical Content