Termination of an intact pregnancy before the time of via-bility can be done to safeguard the health of the mother, because of severe fetal abnormality, or on an elective, that is, voluntary basis. Elective abortion has been legal in the United States since the 1973 Supreme Court decision of Roe v. Wade. Since that time, various local and state lawshave been proposed to significantly limit access to elec-tive abortion. The health care provider should maintain a nonjudgmental position in treating women who may be considering elective termination of pregnancy.
Induced abortion is the medical or surgical termina-tion of pregnancy before the time of fetal viability. In 2004, 839,226 legal induced abortions were reported to the CDC. Medical and/or surgical complications are associated with all choices, with the fewest complications related to elective abortion in the first trimester.
The most common form of suction curettage for first-trimester abortions, vacuum aspiration, requires a rigid cannula attached to an electric-powered vacuum source. Alternatively, manual vacuum aspiration uses a similar cannula that attaches to a handheld syringe for its vacuum source. Second-trimester abortions are most commonly performed through the cervix, using suction or extraction forceps, or by the use of prostaglandins, as in the form of intra-amniotic injections or vaginal suppositories.
Outpatient medical abortion is an acceptable alterna-tive to surgical abortion in appropriately selected women with pregnancies less than 49 days of gestation (calculated from the first day of the last menstrual period). Beyond this point, surgical abortion is the preferred method of early abortion. Three medications for early medical abortion have been widely studied and used: the antiprogestin, mifepristone (RU-486); the antimetabolite, methotrex-ate; and the prostaglandin, misoprostol. These agentscause abortion by increasing uterine contractility either by reversing the progesterone-induced inhibition of contrac-tions—mifepristone and methotrexate, or by stimulating the myometrium directly—misoprostol. Abortion with this medical method is not always complete. As a result, the pa-tient should be made aware that suction curettage may be required.
The most common complications following an induced abortion include uterine perforation, cervical laceration, hemorrhage, incomplete removal of the fetus and placenta, and infection. In cases of postabortal infection, the patient usually presents with fever, pain, a tender uterus, and mild bleeding. Oral antibiotics and antipyretics are usually suf-ficient to manage these mild infections. If tissue remains in the uterus (incomplete abortion), a repeat suction curet-tage is necessary. The second most common complica-tion following induced abortion is bleeding. Risk of death from abortion during the first 2 months of pregnancy is less than 1 per 100,000 procedures, with increasing rates as pregnancy progresses (versus 7.7 maternal deaths per 100,000 live births).
An infected abortion, either complete or incomplete, is known as a septic abortion. Patients may present with sepsis, shock, hemorrhage, and possibly renal failure. It rarely occurs as a complication of a legal abortion, but is more commonly associated with criminal abortions, that is, those done illegally, under unsterile conditions, by per-sons who may have little or no knowledge of medicine or anatomy. Broad-spectrum parenteral antibiotics, intravenousfluid therapy, and prompt evacuation of the uterus are indi-cated. A careful evaluation for trauma, including perfora-tion of the uterus, vagina, or intraabdominal structures, should also be carried out.
Postabortal syndrome develops when the uterus failsto remain contracted after spontaneous abortion (with or without suction curettage) or elective/therapeutic abor-tion. The patient presents with cramping pain and/or bleeding, and is found to have an open cervix, bleeding, and a large, “softer-than-expected” uterus, a result of the collection of blood in the uterus (hematometra). The clin-ical presentation is often indistinguishable from incom-plete abortion. Suction curettage is the treatment for both conditions. Postevacuation treatment with an ergot deriv-ative and an antibiotic reduces the risk of postabortal syn-drome, further bleeding, and infection.