I INDUCED ABORTION

The medical definition of abortion is the interruption of pregnancy after nidation (the intrauterine implantation of a fertilized egg). According to data compiled by the Guttmacher Institute, approximately 1.21 million legal induced abortions were performed in the United States in 2008, which is 8% fewer than in 2000.

Access to Care

Termination of pregnancy before viability is a medical matter between the patient and the physician, subject to the physician’s clinical judgment, the patient’s informed consent, relevant state and federal laws, and the avail­ability of appropriate facilities. The American College of Obstetricians and Gynecologists (the College) supports access to care for all individuals and the availability of all reproductive options, irrespective of financial status. If a termination is chosen, it should be performed safely and as early as possible. The College opposes unnecessary regulations that limit or delay access to care (see also the College’s Abortion Policy statement at www. acog.org/Resources_And_Publications/Statements_of_Policy_List).

Legal Issues

Induced abortion remains one of the most regulated medical procedures in the United States. Although the U.S. Supreme Court has determined that state bans on abortion are unconstitutional, it has upheld many state laws that make abortion services less accessible. These laws include specific physician and hospital requirements, gestational age limits, restrictions on use of state funds and private insurance, waiting periods, required parental involvement, specialized facility requirements, and mandatory informa­tion requirements.

Timing

According to the Centers for Disease Control and Prevention, approxi­mately 64% of abortions are performed before 63 days gestation. Cir­cumstances that can lead to second-trimester abortion include delays in suspecting and testing for pregnancy, delay in obtaining insurance or other funding, and delay in obtaining referral, as well as difficulties in locating and traveling to a health care provider. Poverty, lower education level, and having multiple disruptive life events have been associated with higher rates of seeking second-trimester abortion. In addition, major anatomic or genetic anomalies may be detected in the fetus in the second trimester and women may choose to terminate their pregnancies. Some obstetric and medical indications for second-trimester termination include preeclampsia and preterm premature rupture of membranes, among other conditions.

Methods

Methods of induced abortion include suction (or vacuum) curettage, dilation and evacuation (D&E), medical abortion, and labor-inducing abortion. The type of abortion method chosen depends on several factors, including gestational age, patient health, patient preference, and health care provider experience. Options for first-trimester abortion include suc­tion curettage and medical abortion. Second-trimester abortion methods include D&E, medical abortion, and labor-inducing abortion.

Suction curettage uses cervical dilation (if necessary) followed by a suc­tion device to remove the contents of the uterus. Dilation and evacuation involves cervical dilation followed by the use of grasping forceps to remove the fetus; a final suction curettage often is performed to ensure that the fetus is completely evacuated. Medical abortion involves the use of medi­cations, such as mifepristone and misoprostol, rather than a procedure to induce an abortion. It typically is performed up to 63 days of gestation (calculated from the first day of the last menstrual period), although medical abortion may be used to terminate pregnancies beyond this time.

Complications

The mortality rate associated with abortion is low (0.6 per 100,000 legal, induced abortions), and the risk of death associated with childbirth is approximately 14 times higher than that with abortion. Abortion-related mortality increases with each week of gestation, with a rate of 0.1 per 100,000 procedures at 8 weeks of gestation or less, and 8.9 per 100,000 procedures at 21 weeks of gestation or greater. Complications associated with suction curettage, D&E, and medical abortion include infection, hem­orrhage, cervical laceration, retained products of conception, and failed abortion (ie, ongoing pregnancy). Uterine perforation can occur with suc­tion curettage and D&E, whereas uterine rupture can occur with medical abortion and labor-inducing abortion.

Patient Counseling

Clinicians are not required to perform abortions. However, they should be prepared to counsel patients fully on their options and to manage compli­cations of induced abortions, as needed. Before an abortion, a patient who is undecided should be counseled on her options for the pregnancy. The patient should be fully informed in a balanced manner about all options, including raising the child herself, placing the child for adoption, and abor­tion. The information conveyed should be appropriate to the gestational age and must be delivered without personal bias.

The woman should make a firm decision that she wants an abortion before she decides on the abortion technique. Methods that are appro­priate based on gestational age and patient health should be discussed, including information about the possible complications associated with each technique. Clinicians should address patient concerns about common misconceptions about abortion. Specifically, patients should be informed

that the available evidence concludes that induced abortion is not associ­ated with an increase in breast cancer risk, nor is a patient at increased risk of regret, depression, or infertility after an abortion.

Evaluation and Management

A comprehensive evaluation should be performed before induced abortion and includes the following:

• Complete medical history

• Thorough physical examination

• Screening for vaginitis and sexually transmitted infections, as indi­cated

• Appropriate laboratory testing, as indicated

— Pregnancy test

— Rh determination

— Complete blood count

• Ultrasonography, as indicated, to diagnose pregnancy, establish ges­tational age, and localize the placenta, if indicated

• Consideration for cervical preparation

• Prophylactic antibiotics (for suction curettage or D&E)

• Completion of appropriate paperwork and consent forms, as required by state, hospital, and facility

Clinicians who perform abortions in their offices, clinics, or freestanding ambulatory care facilities should have a plan to provide prompt emergency services if a complication occurs and should establish a mechanism for transferring patients who require emergency treatment. Routine pathologic examination of tissue is not necessary after an induced abortion via suction curettage or D&E in which embryonic or fetal parts can be identified with certainty. In such instances, a description of the gross products of concep­tion should be recorded. The United States has no national system for the mandatory reporting of induced termination of pregnancy. However, state health departments vary greatly in approaches to the compilation of these data, and clinicians should be aware of any such reporting requirements.

The following postprocedure care should be provided:

• Immunoprophylaxis with anti-D immune globulin for women who are RhD-negative

• Counseling on signs of hemorrhage, uterine perforation, retained tissue, infection, and failed abortion, as appropriate

• Psychologic or other support service consultation, as indicated

• Provision of contraception, if desired; except for hysteroscopic sterilization, diaphragm, or cervical cap, all forms of contraception can be considered after abortion and initiated on the day of the procedure; however, intrauterine devices should not be inserted

in the case of immediate postseptic abortion (see also the “Family Planning” section in Part 3).

Clinical training curricula and additional policy guidelines for abortion care are available from the National Abortion Federation (see Resources).

Bibliography­

Abortion access and training. ACOG Committee Opinion No. 424. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:247-50. [PubMed] [Obstetrics & Gynecology]

American College of Obstetricians and Gynecologists. Abortion policy. College Statement of Policy. Washington, DC: American College of Obstetricians and Gynecologists;2011.Availableat:http://www.acog.org/Resources_And_Publications/ Statements_of_Policy_List. Retrieved September 24, 2013.

American College of Obstetricians and Gynecologists. Legislative interference with patient care, medical decisions, and the patient-physician relationship. College Statement of Policy. Washington, DC: American College of Obstetricians and Gynecologists;2013.Availableat:http://www.acog.org/Resources_And_Publications/ Statements_of_Policy_List. Retrieved September 24, 2013.

Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin No. 104. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 113:1180-9. [PubMed] [Obstetrics & Gynecology]

Bartlett LA, Berg CJ, Shulman HB, Zane SB, Green CA, Whitehead S, et al. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol 2004;103:729-37. [PubMed] [Obstetrics & Gynecology]

Grimes DA. Risks of mifepristone abortion in context [editorial]. Contraception 2005;71:161. [PubMed] [Full Text]

Guttmacher Institute. Abortion. Available at: http://www.guttmacher.org/sections/ abortion.php. Retrieved August 15, 2013.

Induced abortion and breast cancer risk. ACOG Committee Opinion No. 434. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113: 1417-8. [PubMed] [Obstetrics & Gynecology]

Jones RK, Kooistra K. Abortion incidence and access to services in the United States, 2008.

Jones RK, Zolna MR, Henshaw SK, Finer LB. Abortion in the United States: inci­dence and access to services, 2005. Perspect Sex Reprod Health 2008;40:6-16. [PubMed] [Full Text]

Medical management of first-trimester abortion. Practice Bulletin No. 143. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:676-92. [PubMed] [Obstetrics & Gynecology]

Pazol K, Creanga AA, Zane SB, Burley KD, Jamieson DJ. Abortion surveillance— United States, 2009. Centers for Disease Control and Prevention. MMWR Surveill Summ 2012;61:1-44. [PubMed] [Full Text]

Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol 2012;119:215-9. [PubMed] [Obstetrics & Gynecology]

Second-trimester abortion. Practice Bulletin No. 135. American College of Obste­tricians and Gynecologists. Obstet Gynecol 2013;121:1394-1406. [PubMed] [Obstetrics & Gynecology]

U S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention. MMWR Recomm Rep 2010;59(RR-4):1-86. [PubMed] [Full Text]

Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of contraceptive methods during the postpar­tum period. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 2011;60:878-83. [PubMed] [Full Text]

Resources

American College of Obstetricians and Gynecologists. Induced abortion. Patient Education Pamphlet AP043. Washington, DC: American College of Obstetricians and Gynecologists; 2011.

Association of Reproductive Health Professionals. Reproductive health topics: abor­tion. Available at: http://www.arhp.org/topics/abortion. Retrieved August 15, 2013. National Abortion Federation. Available at: http://www.prochoice.org. Retrieved August 15, 2013.

Paul M, Lichtenbert ES, Borgatta L, Grimes DA, Stubblefield PG, Creinin MD, edi­tors. Management of unintended and abnormal pregnancy: Comprehensive abor­tion care. West Sussex: Wiley-Blackwell; 2009.

Physicians for Reproductive Health. Available at: www.prch.org. Retrieved August 15, 2013.

Planned Parenthood Federation of America. Available at: http://www.planned parenthood.org. Retrieved August 15, 2013.

Society of Family Planning, Clinical guidelines. Available at: http://societyfp.org/ resources/guidelines.asp. Retrieved June 28, 2013.