Elective Abortion


Article Author:
Maleeha Ajmal


Article Editor:
Rotimi Akinbinu


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
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Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
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Hassam Zulfiqar
Hussain Sajjad
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Muhammad Hashmi
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Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
1/23/2019 9:31:17 AM

Introduction

Elective termination of pregnancy (abortion) is a common procedure despite the ethical and moral controversy surrounding it. With the availability of very accurate over-the-counter pregnancy tests which permit diagnosis of pregnancy 7 to 14 days after conception, termination is often a choice. All abortions performed 9 weeks after the last menstrual period are terminated either medically or surgically. The reasons for terminating a pregnancy may be maternal factors or fetal indications. Preabortion workup usually includes obtaining a complete blood count, coagulation profile, type and crossmatch, sexually transmitted disease screen and levels of human chorionic gonadotropin. An ultrasound is often performed to document the pregnancy. The abortion is usually performed in a clinic or hospital under local anesthesia, with or without conscious sedation.[1][2][3]

Anatomy

External and internal genitalia typically comprise the female genital tract. The external genitalia includes:

  • Mons pubis: A rounded mass of fatty tissue lying over the joint of pubic bones.
  • Labia majora: Two cutaneous folds extend from mons pubis down to the perineum.
  • Labia minora: The region of the female genital tract buried inside the labia majora.
  • Bartholin gland: These are like bulbourethral glands in men, and pour lubrication right at the entry of the vagina.
  • Clitoris: The vagina's pea-sized, most heavily innervated organ that detects sensation and stimulation.
  • Vulva: The collective term for women's external genitalia.

The female reproductive system's internal genitalia includes:

  • Ovaries: Female reproductive organs which produce all the ova (eggs) during a normal menstrual cycle.
  • Fallopian tubes: Also known as uterine tubes, these are responsible for the transportation of ova from the ovaries to the uterus. They are clinically important in abortion because they are the most common site of ectopic pregnancy (pregnancy outside the uterus).
  • Uterus: The womb is a hormone-sensitive reproductive organ where a fertilized ovum implants. It is responsible for nurturing the fertilized ovum, and stages of development inside the mother's body take place in the uterus.
  • Cervix: The lower part of the uterus, or the connection between the uterus and vagina.
  • Vagina: The lowest part of the female genital tract, starting from an external orifice to the cervix.

Understanding of the normal anatomy of the female genital tract is essential. If elective termination of pregnancy fails, operative options are the next step. These options require the knowledge of normal anatomy to avoid any further complications.[4][5][6]

Indications

Elective abortion has no indications because it is carried out at the wish of a mother without any medical reason. Abortion which is carried out for clinical reasons and indicated when there is harm to the mother is known as therapeutic abortion.

Contraindications

Contraindications to an elective medical abortion include an allergy to the drugs used for the elective termination of pregnancy, inherited porphyria, ectopic pregnancy, and chronic adrenal failure. Exercise care in case of any coagulopathy or any other bleeding disorder, but these are not contraindications, the same as with anemia and seizures.

Equipment

Types of equipment used for surgical abortion include:

  • Vacuum single valve aspirator
  • Locking 60 cc syringe
  • Flexible 6 mm cannula with two apertures
  • Rigid 6 mm cannula
  • Flexible 8 mm cannula with the double aperture
  • Specimen cup
  • Standard Graves speculum
  • Moore Graves speculum
  • Single tooth tenaculum
  • Straight sponge forceps
  • Small polyp forceps
  • Pratt cervical dilator
  • Curette

Preparation

Medical abortion preparations include:

  • Tablet misoprostol
  • Tablet mifepristone
  • Medical abortion requires two tablets the prostaglandin analog misoprostol and antiprogesterone mifepristone

For a surgical abortion, arrange all the instruments required for the procedure.

Technique

Medical Abortion

Ultrasound should be carried out first to determine the viability of the pregnancy, whether it is uterine or ectopic. After that, the dating of pregnancy should be determined with the help of an ultrasonogram. The drugs used for medical pregnancy termination include mifepristone and misoprostol. Mifepristone is given orally during the first visit to an abortion clinic. It blocks progesterone synthesis in the female body required to continue the pregnancy. Misoprostol can be taken orally or vaginally about 36 to 72 hours after administration of mifepristone. It prompts the uterus to contract and expel the fetus, which may take a few hours to a few days. A physical examination is carried out after 1 to 2 weeks for the assessment of completion of termination of pregnancy or any other complication related to the abortion.[7]

Surgical Abortion

Suction aspiration and dilation and extraction are the two types of procedures for surgical abortion. Suction aspiration is usually carried out for aborting a pregnancy between 6 and 16 weeks. The patient should lie down on her back in the lithotomy position. The local anesthetic is given first, then tenaculum is used to hold the cervix in place, and it is dilated with the help of absorbent rods varying in thickness. When the cervix is dilated enough, a cannula connected to a suction device is inserted for the aspiration of the fetus and placenta. The procedure usually takes 10 to 15 minutes, and antibiotics are given at the end of the procedure to avoid septic abortion.

The dilation and extraction method is usually carried out after 20 weeks of gestation. A laminaria is inserted into the dilated cervix 48 hours before the procedure, and a small incision is given to the skull of the fetus to evacuate the cerebral material. After that, the fetus is completely removed.[8][9]

Complications

Common side effects of medical abortions include cramping, nausea, diarrhea, severe bleeding, vomiting, and infection (septic abortion). 10% to 12% of medical abortions remain unsuccessful and need an additional surgical procedure for the complete termination of pregnancy.

Common side effects of suction aspiration include cramping, nausea, vomiting, sweating, and hypotension. Less common side effects include prolonged bleeding, infection, damage to the cervix, or perforation of the uterus.

Complications of dilation and extraction can also occur. Common side effects include nausea, vomiting, and bleeding. The patient may experience severe cramps which can last up to 2 weeks. Less common side effects include perforation of the uterus, infection, and blood clots.

Clinical Significance

Surgical procedures to perform an elective abortion include the use of a vacuum device, suction curettage, dilatation and extraction, hysterotomy, or hysterectomy. The risk of complications and morbidity is lower for earlier abortions. Medical abortion is usually performed with methotrexate and a combination of mifepristone and misoprostol. A rare method of accomplishing an abortion is an intra-amniotic injection of digitalis or hypertonic saline. Hypertonic saline has previously been used to induce abortion, but the process is laborious, time-consuming, and often does not work. Abortion has no absolute medical contraindications, but the patient must be stable and free of any acute medical emergencies such as sepsis, coagulopathy, and heart disease. They must also be mentally competent. After the abortion, the patient should avoid sexual intercourse, douche, or the use of tampons. This chapter does not discuss the legal ramifications of elective abortion as they vary by state and country.

Enhancing Healthcare Team Outcomes

Performing elective abortions is a costly affair to the healthcare system. Given the fact that the majority of elective abortions in the US are performed for unintended pregnancies, the focus today is on educating the female on contraceptive management and fertility. The nurse, obstetrician, primary caregiver, and the pharmacist are in the ideal position to educate the female on the different methods of contraception. Because most women post-abortion have a successful ovulation the very next month, time is of an essence. Most obstetricians recommend insertion of an intrauterine device at the time of the elective abortion. The procedure is safe, effective and devoid of any major complications. Finally, both partners must be counseled on contraception if pregnancy is to be avoided in the future. [10][11](Level III)

Outcomes

For the majority of women, the outcome after an elective abortion is excellent. Fertility is not impaired, and all women can have successful future pregnancies. However, the use of contraception is highly recommended to prevent a future problem. [12][13] (Level V)


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Elective Abortion - Questions

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The agent of choice in termination first trimester pregnancy is:



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A 30-year-old married female present with concerns that she is pregnant. She is tearful and states she and her husband are not ready for children. She wants a referral for an abortion. Select the appropriate response.



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A 20-year-old female presents to the clinic with a confirmed 6-week pregnancy. She requests an abortion. Due to personal reasons, the physician does not perform abortions. What should be done by the physician?



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Elective Abortion - References

References

Kotta S,Molangur U,Bipeta R,Ganesh R, A Cross-Sectional Study of the Psychosocial Problems Following Abortion. Indian journal of psychiatry. 2018 Apr-Jun     [PubMed]
Smith BEY,Bartz D,Goldberg AB,Janiak E,     [PubMed]
Vayssière C,Gaudineau A,Attali L,Bettahar K,Eyraud S,Faucher P,Fournet P,Hassoun D,Hatchuel M,Jamin C,Letombe B,Linet T,Msika Razon M,Ohanessian A,Segain H,Vigoureux S,Winer N,Wylomanski S,Agostini A, Elective abortion: Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF). European journal of obstetrics, gynecology, and reproductive biology. 2018 Mar     [PubMed]
Wylomanski S,Winer N, [Role of ultrasound in elective abortions]. Journal de gynecologie, obstetrique et biologie de la reproduction. 2016 Dec     [PubMed]
Thomas EG,Toufaily MH,Westgate MN,Hunt AT,Lin AE,Holmes LB, Impact of elective termination on the occurrence of severe birth defects identified in a hospital-based active malformations surveillance program (1999 to 2002). Birth defects research. Part A, Clinical and molecular teratology. 2016 Aug     [PubMed]
Marret H,Simon E,Beucher G,Dreyfus M,Gaudineau A,Vayssière C,Lesavre M,Pluchon M,Winer N,Fernandez H,Aubert J,Bejan-Angoulvant T,Jonville-Bera AP,Clouqueur E,Houfflin-Debarge V,Garrigue A,Pierre F, Overview and expert assessment of off-label use of misoprostol in obstetrics and gynaecology: review and report by the Collège national des gynécologues obstétriciens français. European journal of obstetrics, gynecology, and reproductive biology. 2015 Apr     [PubMed]
Macisaac L,Darney P, Early surgical abortion: an alternative to and backup for medical abortion. American journal of obstetrics and gynecology. 2000 Aug     [PubMed]
Jackson CB,Foster AM, Ob/Gyn training in abortion care: results from a national survey. Contraception. 2012 Oct     [PubMed]
Porteous J, Oh, by the way, the patient is pregnant! Canadian operating room nursing journal. 2008 Jun     [PubMed]
Mirzamoradi M,Saleh M,Jamali M,Bakhtiyari M,Pooransari P,Saleh Gargari S, Factors related to unwanted pregnancies and abortion in the northern district of the city of Tehran, Iran. Women     [PubMed]
Grange C, [Health education and prevention of abortions in schools]. Revue de l'infirmiere. 2015 Dec     [PubMed]
van Veen TR,Haeri S,Baker AM, Teen Pregnancy: Are Pregnancies following an Elective Termination Associated with Increased Risk for Adverse Perinatal Outcomes? Journal of pediatric and adolescent gynecology. 2015 Dec     [PubMed]
Weber-Schoendorfer C,Chambers C,Wacker E,Beghin D,Bernard N,Shechtman S,Johnson D,Cuppers-Maarschalkerweerd B,Pistelli A,Clementi M,Winterfeld U,Eleftheriou G,Pupco A,Kao K,Malm H,Elefant E,Koren G,Vial T,Ornoy A,Meister R,Schaefer C, Pregnancy outcome after methotrexate treatment for rheumatic disease prior to or during early pregnancy: a prospective multicenter cohort study. Arthritis     [PubMed]

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