Abortion Facts
DEFINITION
Abortion is the expulsion of a fetus before it is mature enough to live on its own.
Legal induced abortion is an abortion that is brought about deliberately by a medical procedure.
DIAGNOSING THE STAGE OF PREGNANCY
Before an abortion is performed, it is important to establish that the woman is indeed pregnant and if so, to measure as accurately as possible how far along is the pregnancy. Since it is difficult to pinpoint the exact moment the woman conceived, health professionals usually refer to a pregnancy in terms of the time that has passed since the first day of the last menstrual period (LMP). The woman is given a pregnancy test, then a pelvic exam. She may also be examined by ultrasound, a painless use of sound waves to "see the inside" and take exact measurements of the contents of the uterus and other pelvic organs.
ALTERNATIVES
Most of us don't think much about abortion (until we get pregnant at the wrong time). .You have the right to choose what is best for you. Each person must consider their options and make a choice.
You can choose:
(a) to continue the pregnancy and keep the baby
(b) to continue the pregnancy and give the baby up either temporarily (foster care); or permanently (adoption)
(c ) to terminate the pregnancy by having a safe, legal abortion. The decision to get an abortion is a personal matter. We will support any decision you make, whatever it may be.
THE RH FACTOR
Your blood will be tested to see if it has the Rh antigen - a protein on the surface of red blood cells.
If it does, your blood type is Rh-positive. If it does not, you are Rh negative. An Rh-negative woman may develop antibodies to an Rh-positive fetus. This causes it to fight the Rh antigen as if it were a harmful substance, and may cause the woman to have serious problems with a future pregnancy or if she ever needs to have a blood transfusion.
To prevent problems, Rh-negative women must get a medication called Rh immune globulin every time they deliver an Rh-positive newborn, or have an abortion, or an ectopic pregnancy. The drug blocks the production of antibodies against the Rh factor.
METHODS TO INDUCE ABORTION
The safest method known for first trimester abortion between 7 - 12 wks is to dilate the cervix and remove the contents of the uterus. This is done by Vacuum Aspiration, which is also known as Suction Curettage. Ninety percent of abortions are performed by suction curettage during the first three months of pregnancy, when abortion is an exceptionally safe procedure.
Recently, two early abortion techniques have been introduced: :
(a) the medication abortion from 5 - 7 wks LMP using RU-486 (Mifeprex) and misoprostol (Cytotec); and(b) the Early Vacuum Aspiration ( "E-V-A" ) from 3 - 7 wks LMP, a modern mini-suction curettage that is used in conjunction with three methods of assuring complete termination of the pregnancy and proactive search for an early ectopic pregnancy. Immediate pre and post suction vaginal ultrasound, stereo microscopy of the aspirate, and in a few selected cases, days 1 and 2 quantitative hCG (blood pregnancy test).
During the second trimester the methods are:
(a) Dilatation and Evacuation (D&E);
(b) Labor Induction which is used primarily towards the end of the second trimester, so that the fetus and placenta are expelled as in a vaginal delivery; and
(c ) Saline induction, which is used uncommonly in a hospital setting.
Anesthesia
Occasionally there are medical or psychological reasons to put the woman to sleep with a general anesthetic. Most abortions, however, can be comfortably and more safely performed with a local anesthetic plus conscious sedation ("twilight anesthesia").
We offer three choices of anesthesia:
(a) Heavy twighlight with intravenous Morphine and Versed for your maximum comfort and safety;
(b) Medium twighlight with a lesser dose of intravenous Morphine and Versed which provides somewhat less sedation; or
(c ) Local anesthesia and oral Valium which is the least expensive.
VACUUM ASPIRATION TECHNIQUE
The safest method known for abortion between 7 - 12 wks is Vacuum Aspiration, also known as Suction Curettage. It is more than 99% effective and extremely safe. Briefly described as follows, the woman lies on an examining table with her feet in knee rests or stirrups. The doctor will first do a pelvic exam by inserting one finger into the vagina while his other hand will press gently on the abdomen to determine the size of the womb. The doctor will then administer the patient's choice of intravenous anesthesia; and washes the vagina with an antiseptic solution (usually Betadine) to reduce the risk of infection. The doctor then inserts a closed speculum into the vagina, then opens it to hold the vaginal walls apart and proceeds to numb the cervix with a local anesthetic.
DILATATION. The physician gradually dilates the cervix in one of two ways. One way is to insert and remove narrow, tapered dilator rods, one at a time, gradually increasing the size of the rod until the opening is about the diameter of a drinking straw (up to half inch). Another method is to insert sterile laminarias (seaweed rods), which absorb moisture from the cervix and gradually expand over a period of several hours, thus slowly enlarging the opening.
ASPIRATION AND CURETTAGE. The physician inserts a small tube that is attached to an aspirator machine similar to the one dentists use to clear the mouth of saliva. The machine's suction empties the contents of the uterus through the tube. Then the doctor carefully checks the walls of the uterus with a spoon-shaped curette; and in early abortions, the doctor will repeat the ultrasound to make certain that the patient is no longer pregnant and no products of conception remain in the uterus.
MEDICAL ABORTION
On September 28, 2000 the FDA approved mifepristone (Mifeprex), also known as RU-486, to medically terminate a pregnancy up to 7 weeks LMP. Mifepristone works faster and is more effective than alternative drugs such as methotrexate. Mifepristone blocks the action of progesterone, a hormone that is needed to sustain the pregnancy. This results in changes in the uterine lining and detachment of the pregnancy; and produces increased sensitivity to misoprostol (Cytotec), a prostaglandin drug that must be used in addition to the RU-486 to successfuly induce the abortion.
Misoprostol can be used orally or preferably, vaginally 1-3 days after RU-486. It causes the uterus to contract and expel the pregnancy, as with a miscarriage. The evacuation of the uterus is not as effective as when performing a vacuum aspiration.
Miscarriage takes 3 days as a minimum but it may occur after several weeks. Contraception may be started immediately after confirmation of a complete abortion. However, patients must wait 10-14 days to repeat a vaginal ultrasound and find out if the abortion was successful or not. Medical abortion has a 5 - 8% failure rate which may require having a suction curettage either because of ongoing or excessive bleeding; an incomplete abortion (tissue remaining in the uterus but there is no growing embryo); or an ongoing viable pregnancy (a growing pregnancy which occurs in less than 1% of cases). If the drugs fail, the abortion must be surgically completed because these medications may cause congenital malformations (patients are precluded from changing their mind). We will not charge for the suction curettage if performed on our premises.
As stated above, medical abortion is only 92% - 95% effective. About 60% of women will have a complete abortion within four hours of using the misoprostol on Day 3; and about 90% will accomplish it by Day 4, within 24 hours after using misoprostol.
Bleeding starts on average 2 - 4 hours after the misoprostol. The heaviest bleeding usually last about 4 hours while the pregnancy is being expelled.
In rare but possible situations, heavy bleeding (defined as soaking one pad per hour for longer than 12 hours) and/or pain may be severe and require an emergency D&C or additional treatment or care, which if not received at our facility will be the patient's financial responsibility and at her own expense. Chance of this happening is less than 1%
Bleeding and/or spotting lasts on average 9-16 days but may continue for as long as six weeks.
Please contact us for help if bleeding more than two (2) maxipads per hour for more than 4 hours in a raw; or if soaking 1 pad per hour for more than 12 hours.
Fever (>101 F) may be due to infection. Call us if you run a temperature over 100.4 or more for more than four hours after using misoprostol; or if fever starts a few days after using misoprostol.
Some women should not have a medical abortion. This includes women who:
(a) have a pregnancy that on ultrasound is more than 7 wks LMP; (b) have or might have an ectopic pregnancy, including women that have no visible gestational sac on ultrasound; ( c) have an intrauterine device (IUD) in place; (d) have a bleeding disorder; (e) take a drug to thin their blood; (f) take certain steroid medicines; (g) have chronic adrenal failure. Medical abortion should be used with caution in women with a serious illness, such as severe anemia and diabetes that is not well controlled; (h) do not have the ability to deal with emergencies during the first 2 or 3 weeks; and would not accept that products of conception and/or clots may be passed at an inconvenient time or place.
INSTRUCTIONS: If you choose to have a medical abortion, on the first visit (Day 1) the doctor will do a sonogram to accurately determine the stage of pregnancy; perform blood work; have you swallow one pill of Mifeprex; and provide you with four small tablets of misoprostol that you will insert vaginally 2 days later (on Day 3). The tablets will work better if moistened with water. Wash your hands before handling the tablets. Lie on your back and with your fingers, insert the tablets, one at a time, deep into the vagina, as high as you can reach. Insert 2 tablets vaginally in early morning and repeat the dose two hours later. Don't insert a tampon; wear a pad. Since you can expect cramping and bleeding and perhaps vomiting and dearhea, you should stay at home at least 8 hours after inserting the misoprostol. If you do not have a substantial bleeding, you will need to come back for a visit and repeat the dose of misoprostol in 24 hours. If you fail to bleed after the second dose of misoprostol, you should promptly return for another visit because this indicates that you may have an undiagnosed ectopic pregnancy.
THE EARLY VACUUM ASPIRATION
E-V-A is preferred by most women seeking an early abortion because it offers many advantages over RU-486:
a) EVA will efficiently complete the abortion in a matter of minutes - in a single office visit - and entails less time lost from work and other activities than the medical abortion. In comparison, RU-486 pill takes several days or even weeks to complete the abortion.
b) the rate of failed abortion is zero when a gestational sac is visible on ultrasound. The ultrasound is performed before and after the suction- while the patient is still on the operating table - to instantly verify the success of the procedure and prevent abortion failures. In comparison, medical abortion has 5-8% rate of failed abortion which is usually discovered by ultrasound, after 7 - 14 days.
c) EVA provides more certainty to the question of an undiagnosed, early ectopic pregnancy because there is tissue available for immediate gross and microscopic examination to identify the villi (pregnancy tissue) in the aspirate which is the gold standard. Villi are identified in 100% of cases that have a visible gestational sac on ultrasound; and in 95% of the cases that have no gestational sac on ultrasound. Finding villi identifies an intrauterine pregnancy, which practically excludes the diagnosis
of an ectopic pregnancy because the coexistence of an intrauterine and extra-uterine pregnancy is very rare, about 1 in 30,000. Medical abortion carries a higher probability of missing an ectopic pregnancy because it relies only on the ultrasound, which in a very early pregnancy is not specific. For example, ectopic pregnancy may be accompanied by an intrauterine decidual reaction that may mimic the appearance of an early gestational sac; and similar images may be present in the non pregnant patient in infections, myomas and bleeding
disorders.
d) EVA can be performed as early as 3 weeks LMP (a full two weeks earlier than a medication abortion) - even when a gestational sac is not found on ultrasound - as long as there is a positive pregnancy test. In comparison, the medical abortion must be cancelled if a visible gestational sac is not found, and is usually performed 5 - 7 weeks LMP.
e) EVA allows to proactive search for possible ectopic pregnancy; and may expedite diagnosing it at an early stage, when drug treatment is possible and emergency surgery and complications may be avoided.Patients value time and certainty of outcome. Most will be reasured prior to leaving the clinic that they are no longer pregnant and did not have an ectopic pregnancy. These patients will not need further testing.
In the 5% minority of patients that show no villi in the aspirate and have no visible gestational sac on ultrasound, two blood pregnancy tests (Days 1 and 2 hCG titers) may be required, which may show that:
(a) the amount of beta hCG hormone increases in the following 24 hours, which indicates an ongoing pregnancy. These patients may have an ectopic pregnancy or a failed abortion.
(b) the hCG drops at least 50% in 24 hours, which indicates a successful termination of an extremely early intrauterine pregnancy; or a successful termination of an abnormal pregnancy (a blighted ovum). Normally, a drop of more than 50% in the blood level of beta hCG 24 hours after the EVA procedure rules out an ectopic pregnancy; and confirms the success of an early termination.
c) Patients experience less bleeding, pain and psychological ill-effects; and recover faster after an EVA. EVA is performed under intravenous sedation to enhance the patient's comfort and decrease her recollection of the events surrounding the procedure. The actual operating time is less than two minutes, which should not be a surprise considering the small amount of tissue that needs to be removed. For example, the size of a 5 wks fetus is 1-2mm; at 6 wks, its size is 5 - 6 mm which is like a grain of rice.
Some of our patients testimonials on the EVA procedure have been:
"I was sure that I wanted to have an abortion and I was very glad that I didn't have to wait to have the procedure performed".
"Thank you for letting me know that I was no longer pregnant and that it was not an ectopic".
"I did not know that the procedure was so quick. I was surprised when I was told it was over".
"I realized that I was in the recovery room but do not remember having had the procedure. . . not even that I walked out of the operating room".
METHODS OF MID-TRIMESTER ABORTION
Terminating the pregnancy is more dificult in mid- trimester because the fetus is larger. Ultrasound staging of the pregnancy is essential.
DILATATION AND EVACUATION (D&E)
This is the most common method. D&E requires considerable skill by the physician but is basically an expansion of the vacuum aspiration technique described earlier.
For pregnancies that are advanced beyond 15 weeks, it is necessary to dilate the cervix using multiple laminaria (seaweed) rods. They are inserted in the cervical canal and left in place overnight. Once the laminarias have been inserted, it is mandatory that the D&E procedure be completed within 48 hours. To perform the abortion, the physician uses suction as in first trimester procedure, and forceps to remove fetal parts that are too large to pass through the suction tube. The procedure is usually completed within 20-30 minutes and is performed under intravenous conscious sedation and local anesthesia of lidocaine and vasopressin.
Our current method of LATE SECOND TRIMESTER (21-22 weeks) abortion involves inserting multiple laminarias into the cervical canal; the serial vaginal placement of misoprostol; and performig a D&E or D&C. The entire procedure is performed on our premises.
A less common method is SALINE INDUCTION which is usually performed in the hospital. Under local anesthesia, the physician passes a needle through the abdomen into the uterus, withdraws some amniotic fluid through the needle and injects saline solution or less commonly, prostaglandin, to induce contractions. Some hours later, the patient goes into labor and expels the fetus. Approximately 75% of the times this occurs within 24 hours.
