eMedicine World Medical Library
 
(advertisement)
Home  |  Specialties | Resource Centers |  CME  |  PDA  |  Contributor Recruitment  |  Patient Education
  Articles Images CME Patient Education Advanced Search  Consumer Health Link to this site
Back to: eMedicine Specialties > Medicine, Ob/Gyn, Psychiatry, and Surgery > Obstetrics/gynecology

Therapeutic Abortion

Last Updated: September 28, 2004
Rate this Article
Email to a Colleague
Synonyms and related keywords: pregnancy termination, fetal viability, maternal health, nonviable fetus, Roe v Wade, abortifacients, RU-486, RU486, mifepristone, misoprostol, methotrexate, MTX, multifetal pregnancy, prenatal diagnostic screening, fetal anomalies, assisted reproductive technologies, hypertensive vascular disease, cardiac disease, cervical cancer

  AUTHOR INFORMATION Section 1 of 10    Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Author: Natalie E Roche, MD, Assistant Professor, Department of Obstetrics, Gynecology and Women's Health, University of Medicine and Dentistry of New Jersey

Natalie E Roche, MD, is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Association of Reproductive Health Professionals, International AIDS Society, National Medical Association, and New York Academy of Sciences

Editor(s): Anthony Charles Sciscione, DO, Director of Fetal Assessment Center, Director of Research, Department of Obstetrics and Gynecology, Medical Center of Delaware, Assistant Professor, Department of Obstetrics and Gynecology, Johns Hopkins University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Richard S Legro, MD, Associate Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Lake Hospital; and Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University; Distinguished Physician, Department of Obstetrics and Gynecology, Northwestern Memorial Hospital
  INTRODUCTION Section 2 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Therapeutic abortion is defined as the termination of pregnancy before fetal viability in order to preserve maternal health. In its broadest definition, therapeutic abortion can be performed to (1) save the life of the mother, (2) preserve the health of the mother, (3) terminate a pregnancy that would result in the birth of a child with defects incompatible with life or associated with significant morbidity, (4) terminate a nonviable pregnancy, or (5) selectively reduce a multifetal pregnancy.

The vast majority of abortions performed in the United States are elective. Pregnancy-related conditions that threaten maternal life are rare and difficult to define precisely. The decision to terminate a pregnancy for medical indications is generally a multidisciplinary decision involving the obstetrician, a specialist in the disease entity in question, the patient, the patient's family, and others.

The methods used to terminate pregnancy vary according to gestational age, the indication for termination, and medical and surgical considerations relevant to the mother. Abortion can be accomplished by surgical or medical means.

Most of this article is devoted to the discussion of indications for therapeutic abortion and medical methods for termination of pregnancy. An in-depth discussion of surgical abortion is covered in Surgical Management of Abortion.

History of the Procedure: Termination of pregnancy has been practiced since ancient times and by all cultures. The indications and social context for termination of pregnancy vary with culture and time.

The use of abortion to preserve the life of the mother has been widely accepted. Early Jewish scholars' interpretation of the Talmud required that the fetus be destroyed if it posed a threat to the mother during delivery. The ancient Greeks allowed abortion under certain circumstances. Ancient Romans did not consider a fetus a person until after birth, and abortion was practiced widely. Early Christians had varying practices regarding abortion. By 1869, the Catholic church declared abortion a sin punishable by excommunication.

In the United States, legislation regarding abortion has varied with the times. Before 1800, no statutes addressed the subject of abortion. The first antiabortion legislation appeared in the 1820s; the preservation of pregnant women's health was the motivating force. During this time, the mortality rate from abortion was high, while the mortality rate from childbirth was less than 3%. By 1900, abortion in the United States at any time during pregnancy was a crime, with the exception of therapeutic abortion performed to save the mother's life.

During the 1950s, the practice of medicine came under increasing scrutiny, and guidelines were set to define the indications for therapeutic abortion. The guidelines allowed therapeutic abortion if (1) pregnancy would "gravely impair the physical and mental health of the mother," (2) the child born was likely to have "grave physical and mental defects," or (3) the pregnancy was the result of rape or incest (Mcfarlane, 1993). In the United States, the legalization of abortion by Roe v Wade in 1973 upheld the fundamental right of a woman to determine whether to continue her pregnancy.

Problem: US statistics indicate that the vast majority of abortions are elective. Therapeutic abortion is rare. The ability to define therapeutic abortion performed for maternal indications is difficult because of the subjective nature of decisions made about potential morbidity and mortality in pregnant women. A variety of medical conditions in pregnant women have the potential to affect health and cause complications that may be life threatening.

Prenatal screening in the form of prenatal diagnostic screening continues to improve the antepartum diagnosis of fetal anomalies. The decision to continue or terminate a pregnancy complicated by fetal anomalies is a difficult decision. The most difficult decisions are associated with anomalies that are unpredictable or highly variable in their expression.

The increase in the use of assisted reproductive technologies has been associated with an enormous increase in multifetal pregnancies. These pregnancies are complicated by increased fetal morbidity and mortality rates, which are largely caused by prematurity and growth retardation. Selective reduction has been introduced as a technology to improve perinatal outcomes in these pregnancies and has been successful in reducing preterm deliveries and associated morbidity and mortality.

Frequency: Approximately 3-5% of all newborns have a recognizable birth defect. According to Cunningham and MacDonald, the suggested causes of fetal anomalies are as follows:

  • Genetic (ie, chromosomal) (20-25%)

  • Fetal infections (3-5%)

  • Maternal disease (4%)

  • Drugs/medications (<1%)

  • Unknown (65-70%)

Medical complications during pregnancy encompass a wide array of medical problems, to include the following:

  • Hypertensive disorders

  • Diabetes mellitus

  • Hematologic disorders

  • Cardiovascular diseases

  • Thromboembolic disorders

  • Thyroid and parathyroid diseases

  • Pituitary disorders

  • Adrenal disorders

  • Renal diseases

  • Hepatic diseases

  • GI tract disorders

  • Pulmonary diseases

  • Infectious diseases

  • Neurologic diseases

  • Psychiatric disorders

  • Malignancies

The diseases tend to occur in frequencies compatible with those of nonpregnant age-matched women. Providing an in-depth review of this wide array of medical problems is beyond the scope of this article.

The most common cancers found in pregnant women mirror those found in their nonpregnant counterparts, to include the following:

  • Cervical cancer (1 case per 2200 pregnancies)

  • Breast cancer (1 case per 3000 pregnancies)

  • Melanoma (0.14-2.8 cases per 1000 pregnancies)

  • Ovarian cancer

  • Thyroid cancer

  • Leukemia (rare)

  • Lymphoma

  • Colorectal carcinoma (0.10-1.0 cases per 1000 pregnancies)

The total incidence of malignancy during pregnancy is estimated at 1 case per 1000 pregnancies.

As previously noted, the number of multifetal pregnancies has increased enormously because of the use of assisted reproductive technologies. Twins have increased in frequency from 1 set per 90 pregnancies to 1 set per 45 pregnancies. Higher-order multifetal pregnancies have quadrupled in the past 20 years.

Clinical: Patients in need of therapeutic termination of pregnancy can be identified at any gestational age; however, the consideration of therapeutic abortion is generally limited to pregnancies at 24 weeks' gestation or less. Many patients are in the second trimester of pregnancy because of the timing of fetal assessment tools (eg, triple screen, amniocentesis, ultrasound).
  INDICATIONS Section 3 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

The indications for therapeutic abortion, in its broadest definition, are as follows:

Therapeutic abortions to save the life of the mother or to preserve the health of the mother are rare events. The decision should be based on the collaborative agreement of a multidisciplinary team. At minimum, the team should consist of the patient, the obstetrician, a specialist with knowledge of the disease in question, an expert in genetic counseling, and a neonatologist. Additional members may include spiritual counselors, nurses, psychologists/psychiatrists, intensive care specialists, ethicists, and family members.

The decision to terminate the pregnancy includes consideration of the effect of the pregnancy on disease outcome, the effect of treatment on fetal outcome, the gestational age of the pregnancy, the level of attachment of the patient to the pregnancy, the desires of the patient and the father, and the availability of family resources/support. This complex situation requires thought and excellent communication among the involved parties regarding the short- and long-term consequences of the decision to abort or continue the pregnancy. The decision must be individualized for each patient. There must be an inherent acceptance of the subjective nature of decisions made in this area. The clinical situations may be rare, and clinical data available may be anecdotal, incomplete, and/or inconclusive.

Commonly accepted medical indications for therapeutic termination of pregnancy include severe hypertensive vascular disease, cardiac disease with cardiac decompensation, and certain malignancies.

Malignancy

Cervical cancer is the most common malignancy affecting pregnant women. Invasive cervical cancer is treated with surgery or radiation; both treatment modalities result in fetal death for the previable fetus. Delay of therapy is the only option that allows fetal salvage in this setting. Treatment delays to allow fetal maturation have been successfully attempted in stages IA and IB. Treatment delays for advanced disease (stages IIB-IV) are controversial. All decisions regarding delay must be individualized and must consider other factors that affect the prognosis (eg, HIV status).

The prognosis for patients with breast cancer is not adversely affected by continuation of pregnancy. The decision to terminate a pregnancy complicated by breast cancer in the first and second trimesters is determined by the degree to which the pregnancy impairs effective treatment and whether treatment presents a risk to the fetus.

The prognosis for patients with melanoma is not improved by therapeutic abortion. Metastatic spread of melanoma to the placenta and fetus has been reported but is very rare. This type of spread has also been reported with lymphoma, leukemia, breast cancer, lung cancer, and stomach cancer and should be addressed when counseling at-risk patients.

Fetal conditions

A pregnancy in which the fetus has defects that are either incompatible with life or associated with significant morbidity can be an indication for therapeutic abortion. The number of fetal conditions that can be identified during pregnancy is always expanding because of improvements in technology available for antenatal diagnosis. The following fetal conditions are identifiable:

  • Chromosomal disorders

  • X-linked disorders

  • Metabolic disorders

  • Neural tube defects

  • Structural anomalies associated with exposure to teratogens

  • Structural anomalies of multifactorial or unknown etiology

Multifetal pregnancies

Multifetal pregnancies are associated with high fetal morbidity and mortality rates. In this setting, morbidity and mortality are associated with high rates of preterm delivery and growth retardation. Preterm birth rates at less than 33 weeks' gestation are 8 times higher for twins and 24 times higher for triplets compared with singleton pregnancies. Each additional fetus in a pregnancy reduces the length of the pregnancy by approximately 3.6 weeks. After birth, the mortality rates for infants born in multiple pregnancies remain elevated from birth to age 5 years, even after controlling for growth restriction.

Multifetal reduction has been shown to reduce the risk of preterm delivery for the remaining fetuses. However, the incidence of prematurity in reduced pregnancies appears to remain higher than in spontaneous pregnancies of the same fetal number. An overall reduction in morbidity-improved survival rates occurs in reduced pregnancies compared with pregnancies in which reduction is not performed.

  RELEVANT ANATOMY AND CONTRAINDICATIONS Section 4 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Relevant Anatomy: Adequate evaluation of uterine size is mandatory. Physical examination may be inadequate for uterine sizing because of the following factors:

Obtaining ultrasound confirmation of gestational age is common practice when a therapeutic abortion is planned. Anticipating potential complications associated with the abortion procedure is important.

Consider anatomic problems that may contribute to technical difficulties during an abortion. Make every attempt to minimize complications because of their impact on a patient who may already experience considerable compromise. A small, stenotic, or scarred cervical os may impair the cervical dilation necessary for safe surgical terminations of pregnancy.

The presence of uterine leiomyomas may make uterine sizing erroneous and the dilation of the cervix difficult or impossible and may contribute to increased blood loss at the time of either surgical or medical abortion procedures.

Abnormal placentation (ie, placenta previa, placenta accreta, placenta percreta) is associated with high parity and previous uterine surgery. This issue must be addressed carefully. Abnormal placentation requires surgical intervention with careful consideration of the anticipated amount of blood loss. The selected surgical abortion method should cause minimal blood loss and be of limited invasiveness. For certain patients, special interventions, such as embolization using interventional radiology techniques, may be needed on a standby basis.

The presence of uterine anomalies (eg, uterus didelphys, unicornuate uterus, septate uterus) may make entering and emptying of the uterus complicated. If surgical abortion is selected, ultrasound guidance during the procedure may be helpful. The abortion of a multiple gestation may make surgical abortions more challenging, and the use of ultrasound guidance is helpful. Data are not available for the use of medical abortion in this setting.

Careful consideration of the choice of anesthesia must be based on the medical, psychiatric, and emotional condition of the patient. Consultation with anesthetists, medical specialists, and psychiatric specialists may be necessary to determine the best choice of anesthesia for an individual patient. In general, local anesthesia affords the greatest safety. General anesthesia for surgical abortions is associated with greater overall risk of anesthesia complications and hemorrhage.

Contraindications: Absolute contraindications to termination of pregnancy are virtually unknown. In the face of significant maternal risk of medical or psychiatric morbidity/mortality, continuation of pregnancy usually presents far greater risk than termination of pregnancy. A particular type of abortion procedure or the timing of abortion may be contraindicated based on the current medical, surgical, or psychiatric condition of a patient. For example, medical abortion is contraindicated in patients with the following conditions:

  • Clotting disorders

  • Severe liver diseases

  • Renal diseases

  • Severe cardiac diseases

  • Long-term steroid use

  • Medical conditions or use of medications that preclude the use of medical abortion medications

  • Adrenal failure

  • Undiagnosed adnexal masses

  • Ectopic pregnancy (except with use of methotrexate)

Medical abortion should be performed with caution in patients with the following conditions:

  • Severe anemia

  • Poorly controlled bowel disease (may cause an exacerbation of symptoms)

Surgical abortion is contraindicated in patients with the following conditions:

  • Hemodynamic instability

  • Profound anemia

  • Profound thrombocytopenia

Instillation abortion techniques are contraindicated in patients with the following conditions:

  • Active pelvic infections

  • Inability to tolerate a solute load (saline only)

  • Asthma, glaucoma, epilepsy, hypertensive cardiovascular disease, pulmonary hypertension (prostaglandin F2a [PGF2a])

  • Fetal demise (saline, urea)

The rare patient with placenta accreta or placenta percreta may require consideration of laparotomy with hysterotomy/hysterectomy despite the increased morbidity and mortality risks associated with these procedures.

Multifetal reduction of pregnancy has inherent risks of rupture of membranes, preterm labor, preterm delivery, and infection, which must be balanced against the benefits of the procedure. Special circumstances, such as the selection of the presenting fetus for reduction, may present a greater risk of loss of the entire pregnancy and must be considered in the risk-benefit analysis.

In patients with significant medical or surgical risk, the choice of abortion procedure must be individualized. All abortion methods may present relative or absolute contraindications for some patients. In the face of limited or absent data for a specific clinical situation, the choice of abortion method is based on the best collective medical judgment of the team of clinicians caring for the patient.

Quick Find
Author Information
Introduction
Indications
Relevant Anatomy And Contraindications
Workup
Treatment
Complications
Outcome And Prognosis
Future And Controversies
Bibliography

Click for related images.

Continuing Education
CME available for this topic. Click here to take this CME.

Patient Education



  WORKUP Section 5 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Lab Studies:

  • Instillation techniques
    • Platelets, coagulation studies, liver function tests, and renal function tests are recommended as baseline testing for instillation methods because of the risk of coagulopathy, vomiting, and diarrhea associated with this method.
  • Selective reduction: No specific laboratory tests are required; however, specific laboratory tests may be ordered for individual patients based on history and physical examination findings.

Imaging Studies:

  • Baseline ultrasounds are routinely used in medical abortion, surgical abortion, and instillation abortion techniques.
  • A chest radiograph may be indicated depending on history and physical examination findings.

Other Tests:

  • Chorionic villus sampling or amniocentesis for fetal chromosome evaluation may be indicated depending on maternal age, obstetric history, family history, or ultrasound findings.

Diagnostic Procedures:

  • Specialized testing is needed for certain indications.
    • For example, fetal umbilical cord blood sampling is indicated when fetal blood must be obtained for diagnostic testing.
    • An ECG may be indicated depending on maternal age, history, physical examination findings, and anesthesia requirements.
Histologic Findings: Collecting tissue for pathologic examination is generally impossible for first-trimester medical abortion and is not part of the recommended protocol. Collection of tissue for pathologic examination for surgical abortion and second-trimester medical abortion is routine.

The obligation to collect tissue from abortion procedures is determined by state abortion regulations and must be addressed in a state-by-state manner. The need to collect tissue for diagnosis of fetal anomalies is addressed on a case-by-case basis. The same state and federal statutes apply for medical and surgical abortions despite the fact that the laws were written for surgical abortion.

  TREATMENT Section 6 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Medical therapy: Medical therapy includes instillation techniques and medical abortion techniques.

Instillation techniques

Instillation agents include hypertonic saline, hypertonic urea, and prostaglandin. All instillation agents function by inducing uterine contractions, which end in the evacuation of the uterine contents.

The instillation technique is performed in a similar fashion for all agents. Selected patients are in the second trimester of pregnancy. The patient empties her bladder, and the abdomen is cleansed with an antiseptic solution. An amniotic fluid pocket can be identified using ultrasound. Alternatively, the skin can be anesthetized using a local anesthetic. An 18-gauge spinal needle is transabdominally introduced into the amniotic sac. Free flow of amniotic fluid is confirmed. (Fluid can be tested with pH paper; urine is acidic, amniotic fluid is basic.) The abortifacient is injected, as follows:

  • Hypertonic saline: Inject 40 g (ie, 200 mL 20% saline).

  • Hypertonic urea: Inject 80 g in 5% D5W.

  • PGF2a: Inject 20-40 mg. Use a test dose of 2.5-5 mg, followed by 17.5-35 mg.

In instillation techniques, the cervix is made inducible by the use of passive dilators (laminaria, Dilapan inserted in cervix) or use of intravaginal prostaglandins (eg, misoprostol, prostaglandin E2 [PGE2] suppositories).

Medical abortion techniques

Medical abortion agents include (1) mifepristone and misoprostol, (2) methotrexate and misoprostol, and (3) misoprostol.

Mifepristone is a progesterone antagonist that blocks the effects of progesterone by competing with endogenous progesterone for receptor binding. The primary effect is on the uterus, where it blocks the effect of progesterone on the endometrium and decidua. The endometrium degenerates and is shed, disrupting the implanted embryo/fetus. The endometrial lining and its contents are expelled. The normal suppression of uterine activity induced in the pregnant uterus by progesterone is lost. The cervix is dilated and softened by poorly understood mechanisms.

Methotrexate is a folic acid antagonist that works by inhibiting dihydrofolate reductase, an enzyme needed to make DNA. In its role as an antimetabolite, methotrexate is toxic to the rapidly dividing cells of the trophoblast.

Misoprostol is a prostaglandin analog that acts by causing uterine contractions, which evacuate the uterine contents.

Mifepristone and misoprostol

Medical abortion using mifepristone and misoprostol at up to 49 days' gestation has been approved by the US Food and Drug Administration (FDA). Patients must meet the following criteria:

The procedure requires 3 visits, as follows:

The following variations on this protocol have been reported in the literature, with low occurrence of adverse effects, good patient acceptance, and comparable effectiveness:

  • Use up to 56 days

  • Self-administration of misoprostol 800 mg per vagina on day 3 at home

  • Repeated dose of misoprostol on day 7 if needed

Methotrexate and misoprostol

See Mifepristone and misoprostol for patient selection criteria. Patients may be up to 63 days from their last menstrual period. The procedure requires a minimum of 3 visits, as follows:

  • Day 1

  • Days 3-5: RhoGAM is administered if needed.

  • Days 5-7

    • Misoprostol 800 mg per vagina is self-administered at home.

    • Alternatively, repeat misoprostol in 24 hours if no vaginal bleeding occurs.

  • Day 8: Assess for completion of abortion using ultrasound.

    • If ultrasound reveals an incomplete abortion, repeat misoprostol.

    • If fetal cardiac activity is present, follow up on day 15.

    • If fetal cardiac activity is absent, follow up on day 36.

  • Day 15: Assess for completion of abortion using ultrasound.

    • If ultrasound reveals an incomplete abortion, repeat misoprostol.

    • If fetal cardiac activity is present, obtain a surgical abortion.

  • Days 29-45: Assess for completion of abortion using ultrasound.

    • If a gestational sac is still observed, obtain a surgical abortion.

    • If fetal cardiac activity is absent, follow up on day 36.

Misoprostol

For medical abortion in the second trimester (17-24 wk), passive dilators are inserted into the cervix. A 200-mg misoprostol tablet is placed in the posterior vaginal fornix, followed by 2 gauze sponges. The misoprostol dose is repeated in 12 hours, and the laminaria and sponges are removed.

Patients are medicated with promethazine, acetaminophen, diphenoxylate, intravenous/ intramuscular analgesics as needed for pain, fever, nausea, and diarrhea. If the fetus does not deliver in 24 hours, add a 20-mg dinoprostone intravaginal suppository every 3 hours until delivery of the fetus occurs. Add intravenous oxytocin 20-30 U/L of Ringer lactate solution to run at 150 mL/h after delivery of the fetus.

Selective reduction

The techniques available for selective reduction include the following:

  • Intracardiac injection (potassium chloride or digoxin)

  • Cord occlusion techniques

    • Embolization with alcohol, enbucrilate gel

    • Nd:YAG laser photocoagulation

    • Fetoscope cord ligation

    • Bipolar cord coagulation

    • Monopolar cord coagulation

Drug Category: Abortifacient agents - Used to produce abortions.

Drug Name
Hypertonic saline, 20% sodium chloride injection (Intra-amniotic injection 20%)
Description Used in second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents. In instillation techniques, cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories).
Adult DoseInject 40 g (200 mL) transabdominally into amniotic sac
Pediatric DoseNot established
Contraindications Increased intra-amniotic pressure, blood disorders (ie, coagulation factor deficiencies, thrombocytopenia, fibrinolytic defects)
Interactions Terbutaline may antagonize effect on uterine activity; indomethacin may increase time from induction to abortion
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsCaution in patients with cardiac disease, hypertension, epilepsy, serious renal impairment, or pelvic adhesions
Drug Name
Hypertonic urea, urea 40-50% injection (Ureaphil)
Description Used in second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents. In instillation techniques, cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories).
Adult Dose Inject 80 g (40-50% solution in D5W) transabdominally into amniotic sac
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; severe renal impairment; frank liver disease; intracranial bleeding; sickle cell anemia
InteractionsAspirin may increase time from induction to abortion
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsMonitor for fluid and electrolyte imbalances
Drug Name
Dinoprost, PGF2a (Prostin F2 Alpha)
DescriptionNot commercially available in the United States. Used in second trimester of pregnancy to induce uterine contractions that end in the evacuation of the uterine contents. Use a test dose of 2.5-5 mg followed by 17.5-35 mg. In instillation techniques, cervix is made inducible by passive dilators (ie, laminaria, Dilapan inserted in cervix) or intravaginal prostaglandins (eg, misoprostol, PGE2 suppositories).
Adult DoseInject 20-40 mg transabdominally into amniotic sac
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; acute pelvic inflammatory disease; wanted pregnancy
InteractionsIncreased effect or toxicity of oxytocic agent
PregnancyX-Contraindicated in pregnancy
PrecautionsCaution in patients with anemia, asthma, diabetes mellitus, epilepsy, compromised uterus (ie, fibroid tumors, surgery), cardiovascular disease, hypertension or hypotension, renal or hepatic impairment; associated with GI distress, flushing, headache, arrhythmias, angina, uterine rupture, dyspnea, wheezing, blurred vision
Drug Name
Mifepristone, RU-486 (Mifeprex)
DescriptionProgesterone antagonist. Competes with endogenous progesterone for receptor binding on the endometrium and decidua. Normal suppression of uterine activity induced in the pregnant uterus by progesterone is lost. Endometrium degenerates and is shed, disrupting the implanted embryo/fetus. Endometrial lining and its contents are then expelled. The cervix is dilated and softened by poorly understood mechanisms.
Adult Dose<49 days since LMP: 600 mg mifepristone PO as single dose, follow in 48 h with 400 mcg misoprostol PO
Alternative: 600 mg mifepristone PO as single dose, follow in 48 h with 800 mcg misoprostol PO; may repeat misoprostol on day 7 prn; regimen may be effective up to 56 d since LMP
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; anticoagulant therapy; bleeding disorders; contraceptive devices (IUDs); ectopic pregnancy; adrenal insufficiency
InteractionsDecreases effect of corticosteroids; increases levels of warfarin, alfentanil, benzodiazepine (ie, alprazolam, triazolam, midazolam); antiretroviral protease inhibitors; calcium channel blockers (ie, nifedipine, diltiazem, verapamil); carbamazepine; cilostazol; cyclosporine; fentanyl; atorvastatin, lovastatin, simvastatin, cerivastatin (removed from US market 8/8/01); quinidine; quinine; sertraline; adverse cardiac effects, cisapride, dofetilide, pimozide
PregnancyX - Contraindicated in pregnancy
PrecautionsCaution in patients with cardiovascular disease, pulmonary disease (ie, asthma, COPD), diabetes mellitus, renal or hepatic impairment
Drug Name
Methotrexate (Folex PFS, Rheumatrex)
DescriptionFolic acid antagonist inhibits dihydrofolate reductase, an enzyme needed to make DNA. Antimetabolite property is toxic to the rapidly dividing cells of trophoblast. Methotrexate and misoprostol regimen may be used up to 63 d since LMP.
Adult Dose50 mg/m2 IM or 50 mg PO, followed by 800 mcg misoprostol PV 5-7 d later, may repeat misoprostol in 24 h if no vaginal bleeding occurs
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency
InteractionsOral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response; coadministration with NSAIDs may be fatal; indomethacin and phenylbutazone can increase plasma levels; may decrease phenytoin serum levels; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity; may increase plasma levels of thiopurines
PregnancyD- Unsafe in pregnancy
PrecautionsHas toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested)
Drug Name
Misoprostol (Cytotec)
DescriptionSynthetic prostaglandin E1 analog. Abortifacient effect results from increased frequency of uterine contractions. May be used alone or as part of regimen with mifepristone up to 49 d since LMP or with methotrexate up to 63 d since LMP.
Adult Dose During second trimester (17-24 wk): 200-mcg tab placed in posterior vaginal fornix, repeat in 12 h; if fetus not delivered in 24 h, add 20-mg dinoprostone intravaginal supp q3h until delivery of fetus
With mifepristone: 400 mcg PO 48 h after mifepristone
With methotrexate: 800 mcg PV 5-7 d after methotrexate, if no vaginal bleeding repeat in 24 h
Pediatric Dose Not established
Contraindications Documented hypersensitivity
InteractionsNone reported
PregnancyX - Contraindicated in pregnancy
PrecautionsCaution in patients with renal impairment and in elderly patients
Drug Name
Dinoprostone, PGE2 (Prostin E2 suppository)
DescriptionInduces uterine contractions by stimulating myometrium. Used during second-trimester medical abortions if fetus does not deliver in 24 h. Also used during instillation technique abortions to make cervix inducible.
Adult DoseMedical abortion: 20 mg PV q3h until delivery of fetus occurs
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; acute pelvic inflammatory disease; uterine fibroids; cervical stenosis
InteractionsIncreased effects of oxytocics
PregnancyC - Safety for use during pregnancy has not been established.
Precautions Caution in patients with anemia, asthma, cervicitis, infected endocervical lesions, acute vaginitis, diabetes mellitus, epilepsy, compromised uteri (ie, fibroid tumors, surgery), cardiovascular disease, hypertension or hypotension, renal or hepatic impairment; associated with GI distress, headache, arrhythmias, angina, uterine rupture, dyspnea, wheezing

Surgical therapy: Surgical abortion techniques available for therapeutic termination of pregnancy include the following:

  • Manual vacuum aspiration (ie, menstrual extraction)

  • Suction curettage

  • Dilation and extraction

  • Hysterotomy

  • Hysterectomy

The choice of surgical abortion technique depends on the gestational age of the pregnancy; the expertise of the available medical staff; the clinical importance of obtaining an intact fetus; and the medical, surgical, psychiatric, and anesthetic contraindications to the various techniques. See Surgical Management of Abortion for a detailed discussion of surgical abortion techniques.

Preoperative details: For selective reduction procedures, evaluation of the fetuses using chorionic villus sampling or amniocentesis can assist in selection of the appropriate fetuses for reduction.

The use of ultrasound to assess fetal growth, fetal heart rate, and fetal nuchal thickening can also be helpful in the selection process. Criteria such as nuchal translucency of more than 3 mm, a lag in growth longer than 3 days, or a heart rate less than 80 beats per minute can be used to select the appropriate fetus for reduction.

Follow-up care: For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Procedures Center. Also, see eMedicine's patient education articles Abortion, Miscarriage, and Dilation and Curettage (D&C).

  COMPLICATIONS Section 7 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

As with all interventions, complications are associated with all methods used for termination of pregnancy. For complications associated with surgical abortion, see Surgical Management of Abortion. Medical abortions in the first trimester are safe and well-tolerated procedures. The major problems are decreased effectiveness of medical abortion with increasing gestational age and the long interval between administration of medication to completion of abortion for certain medications (eg, methotrexate, tamoxifen).

Complications and adverse effects associated with specific medications are as follows:

  • Methotrexate and misoprostol: Complications associated with the proper dose are rare, but the following can occur:

    • Stomatitis (0.66%)

    • GI morbidity

      • Nausea (10-37%)

      • Vomiting (7-25%)

      • Diarrhea (2-52%)

    • Thrombocytopenia

    • Chemical hepatitis

    • Failed abortion (4-12%)

  • Mifepristone and misoprostol

    • Transfusion (0.1%)

    • Pain requiring narcotic analgesia (4-15%)

    • Vomiting (12-44%)

    • Diarrhea (7-39%)

    • Failed abortion (2-6%)

  • Misoprostol and tamoxifen

    • Vomiting (28%)

    • Diarrhea (8%)

    • Failed abortion (8%)

  • Misoprostol alone

    • Nausea (24%)

    • Vomiting (25-26%)

    • Diarrhea (58%)

    • Headache (13-15%)

    • Fever (35%)

    • Chills (54-57%)

    • Failed abortion (6-8%)

Complications associated with instillation techniques are as follows:

  • Hemorrhage requiring transfusion (0.32-1.72%)

  • Infection

  • Incomplete abortion

  • Cervical laceration

  • Hypernatremia and sodium load (saline)

  • Muscle necrosis (myometrial injection of saline or urea)

  • Adverse GI effects

  • Unintended surgery (0.04-0.08 cases per 100 instillations)

  • Disseminated intravascular coagulopathy (saline, 658 cases per 100,000 instillations)

Urea instillation abortions are reported to be safer than saline abortions. Prostaglandin-induced second-trimester abortions are safer than saline abortions and have a lower induction-to-completion time.

Of all methods of second-trimester abortion, the safest procedure (using mortality surveillance data) is dilation and extraction. Intermediate risk of mortality occurs with instillation procedures. The highest mortality rates for second-trimester abortions are associated with major surgical procedures (ie, hysterotomy, hysterectomy).

Selective reduction procedures are not included in the statistics for second-trimester abortions. For the rare condition of monochorionic twins, selective reduction cord occlusion techniques are reported by Challis et al to have premature rupture of membranes in up to 30% of cases. The more common method of intracardiac injection techniques for selective reduction is associated with premature rupture of membranes in 13% of triplet pregnancies reduced to twins and in 19.3% of quadruplets reduced to twins. The risk of miscarriage in a pregnancy undergoing selective reduction is inversely proportional to the number of fetuses in the initial pregnancy (ie, quintuplet, 24.8%; triplet, 8.3%)

  OUTCOME AND PROGNOSIS Section 8 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Advantages of medical abortion are as follows:

Advantages of surgical abortion are as follows:

  • More effective than medical abortion

  • Shorter completion time

  • Shorter bleeding duration

  • No exposure to potential teratogens

  • Can be performed later in gestational age

  • Fewer visits

Surgical abortion is 99% effective in terminating pregnancy. Medical abortion using mifepristone and misoprostol has a mean effectiveness of 94%. Medical abortion using methotrexate and misoprostol has effectiveness ranging from 88-96%. Medical abortion in the second trimester using misoprostol has effectiveness ranging from 40-89% within 24 hours. Instillation methods of abortion have effectiveness ranging from 81-86% at 48 hours to 97% at 72 hours.

As with all interventions, complications are associated with all the methods of termination of pregnancy. For complications associated with surgical abortion techniques, see Surgical Management of Abortion.

Medical abortions in the first trimester are very safe and well-tolerated procedures. The major problem is decreased efficacy with increasing gestational age. In the case of methotrexate, a long period of time between administration of medication to abortion is problematic.

First-trimester abortions performed by surgical or medical methods are well tolerated, have little effect on future fertility, and are not associated with long-term psychological consequences. Second-trimester abortions are well known to be associated with increased risk of morbidity and mortality with increasing gestational age. An association of increased risk for preterm delivery after dilation with metal dilators has been reported.

  FUTURE AND CONTROVERSIES Section 9 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Future research is expected to evaluate alternative protocols for medical abortion. Research is expected to continue evaluating other medications for medical abortion, including further research using the following:

The potential exists for wider use of medical management of incomplete and missed abortions as the techniques for medical abortion become commonplace.

  BIBLIOGRAPHY Section 10 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

  • ACOG: American College of Obstetricians and Gynecologists. Methods of Midtrimester Abortion. ACOG Technical Bulletin 1987; 109: 602-05.
  • Ashok PW, Templeton A: Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases. Br J Obstet Gynaecol 1999 Jul; 106(7): 706-10[Medline].
  • Ballagh SA, Harris HA, Demasio K: Is curettage needed for uncomplicated incomplete spontaneous abortion? Am J Obstet Gynecol 1998 Nov; 179(5): 1279-82[Medline].
  • Begley AM: Preparation for practice in the new millennium: a discussion of the moral implications of multifetal pregnancy reduction. Nurs Ethics 2000 Mar; 7(2): 99-112[Medline].
  • Bernstein PS, Rosenfield A: Abortion and maternal health. International Journal of Gynaecology Obstetrics 1998; 63 Suppl 1: S115-22[Medline].
  • Borgmann CE, Jones BS: Legal issues in the provision of medical abortion. Am J Obstet Gynecol 2000 Aug; 183(2 Suppl): S84-94[Medline].
  • Bourguignon A, Briscoe B, Nemzer L: Genetic abortion: considerations for patient care. J Perinat Neonatal Nurs 1999 Sep; 13(2): 47-58[Medline].
  • Challis D, Gratacos E, Deprest JA: Cord occlusion techniques for selective termination in monochorionic twins. J Perinat Med 1999; 27(5): 327-38[Medline].
  • Chung TK, Lee DT, Cheung LP, et al: Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertil Steril 1999 Jun; 71(6): 1054-9[Medline].
  • Cunningham GF, MacDonald PC, Gant NF: Abortion. In: Williams Obstetrics. 19th ed. 1993: 661-90.
  • Delfs,E, Katayama, KP: Surgical Management of Reproductive Failure and Abortion. Te Linde's Operative Gynecology 1977; Fifth Edition: 429-451.
  • Elul B, Ellertson C, Winikoff B, Coyaji K: Side effects of mifepristone-misoprostol abortion versus surgical abortion. Data from a trial in China, Cuba, and India. Contraception 1999 Feb; 59(2): 107-14[Medline].
  • Gouk EV, Lincoln K, Khair A, et al: Medical termination of pregnancy at 63 to 83 days gestation. Br J Obstet Gynaecol 1999 Jun; 106(6): 535-9[Medline].
  • Grimes DA, Schulz KF: Morbidity and mortality from second-trimester abortions. J Reprod Med 1985 Jul; 30(7): 505-14[Medline].
  • Jain JK, Meckstroth KR, Mishell DR Jr: Early pregnancy termination with intravaginally administered sodium chloride solution-moistened misoprostol tablets: historical comparison with mifepristone and oral misoprostol. Am J Obstet Gynecol 1999 Dec; 181(6): 1386-91[Medline].
  • Kjems E, Krag C: Melanoma and pregnancy. A review. Acta Oncol 1993; 32(4): 371-8[Medline].
  • Kruse B, Poppema S, Creinin MD, Paul M: Management of side effects and complications in medical abortion. Am J Obstet Gynecol 2000 Aug; 183(2 Suppl): S65-75[Medline].
  • Macisaac L, Darney P: Early surgical abortion: an alternative to and backup for medical abortion. Am J Obstet Gynecol 2000 Aug; 183(2 Suppl): S76-83[Medline].
  • Mayr NA, Wen BC, Saw CB: Radiation therapy during pregnancy. Obstet Gynecol Clin North Am 1998 Jun; 25(2): 301-21[Medline].
  • Mcfarlane DR: Induced abortion: an historical overview. Am J Gynecol Health 1993 May-Jun; 7(3): 77-82[Medline].
  • Medich DS, Fazio VW: Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy. Surg Clin North Am 1995 Feb; 75(1): 77-88[Medline].
  • Miller VL, Ransom SB, Shalhoub A, et al: Multifetal pregnancy reduction: perinatal and fiscal outcomes. Am J Obstet Gynecol 2000 Jun; 182(6): 1575-80[Medline].
  • Nielsen S, Hahlin M, Platz-Christensen J: Randomised trial comparing expectant with medical management for first trimester miscarriages. Br J Obstet Gynaecol 1999 Aug; 106(8): 804-7[Medline].
  • Oteri O, Hopkins R: Second trimester therapeutic abortion using mifepristone and oral misoprostol in a woman with two previous caesarean sections and a cone biopsy. J Matern Fetal Med 1999 Nov-Dec; 8(6): 300-1[Medline].
  • Papiernik E, Grange G, Zeitlin J: Should multifetal pregnancy reduction be used for prevention of preterm deliveries in triplet or higher order multiple pregnancies? J Perinat Med 1998; 26(5): 365-70[Medline].
  • Perry KG Jr, Rinehart BK, Terrone DA, et al: Second-trimester uterine evacuation: A comparison of intra-amniotic (15S)-15-methyl-prostaglandin F2alpha and intravaginal misoprostol. Am J Obstet Gynecol 1999 Nov; 181(5 Pt 1): 1057-61[Medline].
  • Sandstrom O, Brooks L, Schantz A, et al: Interruption of early pregnancy with mifepristone in combination with gemeprost. Acta Obstet Gynecol Scand 1999 Oct; 78(9): 806-9[Medline].
  • Schaff EA, Fielding SL, Eisinger SH, et al: Low-dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception 2000 Jan; 61(1): 41-6[Medline].
  • Sorosky JI, Scott-Conner CE: Breast disease complicating pregnancy. Obstet Gynecol Clin North Am 1998 Jun; 25(2): 353-63[Medline].
  • Vintzileos AM, Ananth CV, Smulian JC, et al: Routine second-trimester ultrasonography in the United States: a cost- benefit analysis. Am J Obstet Gynecol 2000 Mar; 182(3): 655-60[Medline].
  • Wiebe ER: Tamoxifen compared to methotrexate when used with misoprostol for abortion. Contraception 1999 Apr; 59(4): 265-70[Medline].

NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

Therapeutic Abortion excerpt

© Copyright 2004, eMedicine.com, Inc.

About Us | Privacy | Terms of Use | Contact Us | Advertise | Institutional Subscribers