Continuing Education Activity

Abortion is one of the common procedures performed among women. In the US, in 2014, one in 5 pregnancies ended in abortion, and one in 4 women is estimated to have an abortion in their lifetime. Globally, one in 4 pregnancies ends in abortion. It is important that all providers understand the prevalence of abortion, the options available, the safety, the restrictions, and the access issues associated with abortion to be able to provide safe and optimal quality of care to the patients. This activity reviews the options available to the woman when she has a positive pregnancy test, describes the various methods of safe abortion care, outlines the indications, contraindications of the various methods of abortion, explains the techniques of performing an abortion, outlines the complications and the steps that help manage these complications.

Objectives:

• Describe options available to a woman with a positive pregnancy test.
• Explain the methods of abortion available and describe the pros and cons of each method.
• Outline steps of a medical abortion, identify complications and explain how these can be managed.
• Outlines steps of an aspiration or surgical abortion, identify complications and explain how these can be managed.

Introduction

Abortion is one of the common procedures performed among women. In the US, in 2014, one in 5 pregnancies ended in abortion, and one in 4 women is estimated to have an abortion in their lifetime[1]. Globally, one in 4 pregnancies ends in abortion. It is important that all providers understand the prevalence of abortion, the options available, the safety, the restrictions, and the access issues associated with abortion to be able to provide safe and optimal quality of care to the patients.

A committee of the National Academies of Sciences, Engineering, and Medicine reviewed the data available and confirmed in their report in 2018 that all forms of abortion including medication and aspiration abortion are safe and effective and that the only factors decreasing safety are those decreasing access [2][3].  First trimester abortions pose no long-term risk of infertility, ectopic pregnancy, spontaneous abortion, or breast cancer.  Abortion does not pose a hazard to a patient’s mental health[4]. 

Abortion can be completed with medication or by a procedure which is often called surgical abortion or aspiration abortion. The reasons for terminating a pregnancy may be maternal factors or fetal indications. Preabortion workup often includes obtaining a complete blood count, coagulation profile, type and crossmatch, sexually transmitted infection screen, human chorionic gonadotropin levels, and a pelvic ultrasound to confirm that the pregnancy is intrauterine. Medication abortion can be completed at home. The aspiration abortion is usually performed in a clinic or hospital under local anesthesia, with or without conscious sedation.[5][6][7]

Anatomy and Physiology

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 that 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 the normal anatomy of the female genital tract helps manage complications of medication abortion and perform the aspiration or surgical abortion.

Indications

According to the National Abortion Federation 2020 clinical policy guidelines for abortion care, any patient choosing to have an abortion must be counseled in a nonjudgmental manner about their options. The patient’s desires must be explored and options including continuing the pregnancy, parenting, adoption, and termination of pregnancy should be discussed during this time. If the patient desires to end the pregnancy then the benefits, risks, and details of the process need to be discussed. 

Early medication abortion is non-invasive, avoids the risk of a surgical procedure and the risk of anesthesia can be done up to 11 weeks. It allows for more privacy and control for the patient. It usually involves the use of medications such as mifepristone and misoprostol and rarely methotrexate[8][9][10]. Medication abortion after the first trimester can also be performed safely and effectively by trained clinicians in settings that are equipped to support the patient. Induced fetal demise may be necessary for later gestational ages.

Aspiration or surgical abortion involves a procedure and the use of instruments in the vagina, cervix, and uterus to remove the pregnancy. The procedure is usually short. Aspiration abortion might be needed if medication abortion fails or the woman bleeds heavily during the medication abortion. According to the 2020 National Abortion Federation Clinical Policy Guidelines for Abortion Care, the incidence of aspiration after medication abortion is 2-9% for >63 days LMP and even less to <1% to 3% when the second dose of misoprostol is used. The other indication for aspiration or surgical abortion is suspected molar pregnancy [11] 

Contraindications

Contraindications to medication abortion include

• IUD in place - may be removed before the medication abortion
• Allergy to medication used 
• Chronic adrenal failure, and especially patients who are on long term systemic corticosteroid therapy
• Suspected ectopic pregnancy
• Hemorrhagic disorders
• Anticoagulant therapy excluding aspirin
• Hemodynamic instability 
• Inherited porphyria

Anemia, seizures, asthma on steroid inhalers, obesity, breastfeeding, HIV or AIDs, and sexually transmitted infection are not considered contraindications. 

Exercise care in case of any coagulopathy or any other bleeding disorder, but these are not contraindications for surgical or aspiration abortion. In case the products of conception are not confirmed on the aspirate after a surgical abortion, trend the HCG levels to ensure ectopic pregnancy or pregnancy of unknown location is ruled out and treated if this is the case. 

Equipment

Equipment used for aspiration abortion include:

• Vacuum single valve aspirator/Manual vacuum aspirator plus
• Locking 60 cc syringe
• Cannula
• Specimen cup
• Standard Graves speculum
• Single tooth tenaculum
• Ring forceps with cotton
• Small polyp forceps
• Pratt cervical dilators
• Gauze
• Curette

Preparation

Medical Abortion

Once the pregnancy test is positive and the patient has opted for abortion, take the following steps to ensure the patient is eligible for medication abortion.

Confirm the last menstrual period(LMP) and estimate the gestational age(GA). The first day of LMP alone is an accurate means of estimating the gestational age through the mid-first trimester. If the LMP is not known or unreliable, obtain an ultrasound to date the pregnancy. There is no need for an ultrasound prior to medication abortion in all cases[12]

Take a detailed medical history from the patient including allergies, review of medical conditions, medications, and substance use. Complete a physical exam if indicated by the patient’s history and symptoms. Patients choosing medication abortion with a definite LMP do not need a pelvic exam. The pelvic and bimanual exam may be performed prior to the procedure. Patients with no medical conditions do not need routine pre-abortion lab testing. Labs that are recommended include glucose for patients with Insulin Dependent Diabetes Mellitus, INR for those on anticoagulants (warfarin) beyond 12 weeks of GA, rhesus D testing for consenting patients beyond 56 days from LMP and unknown Rh status, hemoglobin and hematocrit only for those with history or symptoms of anemia, gonorrhea and chlamydia testing for those at increased risk or less than 25 years of age. When clinical dating is uncertain, an ultrasound scan is performed to confirm the location and viability of the pregnancy. Combined mifepristone/misoprostol regimens are more effective than misoprostol alone or methotrexate/misoprostol[13].

According to the National Abortion Federation (NAF) 2020 guidelines, after counseling the patient about the methods and the pros and cons of the procedure, determine pregnancy dating and eligibility for medication abortion by one of the following.  

1. LMP< or = 77 days from the anticipated date of mifepristone use and
1. First positive pregnancy test less than 6 weeks ago
2. No ectopic risk factors including previous ectopic pregnancy, history of Pelvic Inflammatory Disease, Intra Uterine Device in place at the time of conception, bleeding since LMP, unilateral pelvic pain
3. Regular menses with no hormonal contraception use 2 months prior to LMP
2. LMP and physical examination including a bimanual examination if needed
3. Pelvic ultrasound to date the pregnancy

Ensure the patient has no contraindications for medication abortion. Obtain signed informed consent including the manufacturer’s patient agreement and medication guide from the patient after discussing the risks involved in medication abortion and the side effects of the medication.

Side effects of mifepristone include mainly vaginal bleeding. Side effects of misoprostol include nausea, vomiting, diarrhea, low-grade fever, muscle aches that resolve within 6 hours of use. If the mifepristone or misoprostol are vomited less than 15 to 30 minutes of use, repeating the dosing can be considered. Antiemetic medications can help manage nausea and vomiting. Vaginal bleeding usually starts 4 to 6 hours after misoprostol use and can be heavy with clots. Patients bleeding heavier than 2 pads per hour or for over 2 hours need to be evaluated by the clinician. Bleeding lasts from 1 to 45 days. Patients need to be informed of the risks including heavy bleeding that may need additional doses of misoprostol, NSAIDs, the need for aspiration in some cases, the small risk for endometritis, failure of medication abortion needing additional doses of misoprostol or aspiration, teratogenicity of misoprostol. The patient’s phone number or email is confirmed. Lastly, transportation for follow-up is ensured.

Surgical Abortion

After taking a detailed medical history, pregnancy must be confirmed, gestational age must be assessed. Ultrasound is often used to confirm the location of the pregnancy. Baseline vitals including pulse, blood pressure must be performed for all and a physical exam for those indicated by patient symptoms and history. Confirm and arrange all the instruments required for the procedure ahead of time. 

Technique

Medical Abortion

Mifepristone/Misoprostol protocol

Mifepristone - one 200mg tablet is swallowed on day 1 in the clinic or at home. Misoprostol can be administered in the following routes

1. Buccally: Four 200mcg tablets are placed between gum and cheek for 30minutes and swallowed thereafter, 24 to 48 hours after mifepristone administration. 
2. Vaginal: Four 200mcg tablets of misoprostol can also be placed in the vagina, 6 to 48 hours after the mifepristone
3. Sublingual: Two to four 200mcg tablets of misoprostol under the tongue for 30 minutes

According to the NAF 2020 guidelines, if a patient is > 63 days from LMP, a second dose of 800mcg misoprostol can be administered 4 hours after the first dose. If patient >70 days from LMP, a second dose of 800mcg misoprostol is recommended 4 hours after mifepristone.

NSAIDs help pain management for the patient while at home[14] and the routine prescription of opiates is not necessary. A short prescription for opiates may be prescribed in case NSAIDs are not tolerated or cannot be used due to an allergy. Prophylactic antibiotics are not routinely recommended for medical abortion. Contraception can be discussed if the patient is willing to engage at this time.

The patient is instructed to contact the provider if 

1. Bleeding heavily, soaking 2 or more pads in 2 or more consecutive hours
2. Severe pain that is not responding to the medication prescribed
3. Fever of more than 100.4 degrees Celsius for more than 24 hours after misoprostol
4. No bleeding within 24 hours of misoprostol
5. Nausea, vomiting, diarrhea, abdominal pain more than 24 hours after misoprostol

According to the NAF 2020 guidelines, ultrasound is not needed to confirm the completion of a successful abortion if using clinical history and home pregnancy tests[15]. It can be performed by checking baseline serum HCG on the day of mifepristone and one after misoprostol. A decrease of hCG of 50% from baseline by 72 hours, 60% by 4-5 days[16], and 80% by 7 days from initiating treatment[17]are confirmative of a successful MAB. It can also be confirmed by ultrasound examination before and after medication administration. An absence of the gestational sac or embryo confirms the success of the abortion.

According to the NAF 2020 guidelines, when methotrexate and misoprostol are used, an evidence-based regimen of oral or intramuscular methotrexate followed in three to five days with vaginal misoprostol is recommended for gestations up to 63 days

Surgical/Aspiration Abortion 

Aspiration abortion is performed up to 16 weeks.

Technique: Don gloves, perform a bimanual examination, and confirm the uterine position and size. Confirm you have all the equipment you need. Adjust table and light, insert the speculum, evaluate and collect samples for infection screening and testing. Apply the antiseptic solution to the cervix. Administer a paracervical block if the patient is awake. Place tenaculum on the cervix. Dilate the cervix to the size of the cannula you will be using ( gestational age in weeks + or - 1 to 2 mm). The cervix is dilated using tapered dilators like Pratt or Denniston dilators [18]. Misoprostol can also be used for cervical preparation prior to procedure [19][20][21]. Osmotic dilators are used when cervical dilation is expected to be difficult. Insert cannula through the cervix with gentle but firm traction on the cervix using the tenaculum. Connect the aspirator to the cannula. The procedure is completed by aspiration of the uterus using a manual or electric vacuum and not by sharp curettage. The procedure is considered complete when the uterus is empty. Ultrasound can be used to confirm the completion of the procedure. Remove the tenaculum and the speculum. Check for the adequacy of the products of conception. If molar pregnancy is suspected, send the tissue to the pathologist for examination. Inform the patient of the complete procedure and the recovery process. The procedure usually takes 5 to 10 minutes, and antibiotics are given at the end of the procedure to avoid infection.

Dilatation and Evacuation is performed beyond 16 weeks by experienced clinicians in appropriate clinical settings. Intravenous access should be established prior to the procedure. If induced fetal demise is used, appropriate evidence-based protocols must be followed. Osmotic dilators including Dilapan and laminaria, misoprostol, mifepristone, and or other cervical agents are used to achieve adequate dilation. Osmotic dilators may be placed in the cervix prior to the procedure. All instruments entering the uterine cavity must be sterile. Ultrasound should be used during the procedure to locate fetal parts, visualize instruments, and verify completion of the procedure thus reducing the risk of uterine perforation and shortening the procedure[22][23]. Uterotonics must be used to help control uterine bleeding during and after the procedure.

Complications

 Complications of Medication abortion [10][24]and the management options when these arise include the following:

1. Heavy bleeding and or severe cramping. 
1. Repeat misoprostol/NSAIDs
2. Uterine aspiration 
3. Blood transfusion[25]
2. Failure of medication abortion
1. Uterine aspiration
2. Repeat misoprostol[26]
3. Infection - endometritis (fever>24 hours after misoprostol, abdominal and pelvic pain, vaginal discharge, uterine/adnexal tenderness)
1. Uterine aspiration if retained pregnancy tissue in the uterus and antibiotics per CDC guidelines 
2. Immediate admission to the hospital will be required if hemodynamically unstable and aggressive treatment with antibiotics. 
4. Ectopic pregnancy
1. Treat or refer for next steps 

Aspiration Abortion[27]

1. Vasovagal episode 
1. Cool compresses
2. Elevate legs above the chest
3. Isometric extremity contractions
4. Atropine IM 0.4mg or 0.2mg IV, max dose 2mg
2. Heavy bleeding - remember 6 Ts[28]
1. Tone - Uterine massage and consider uterotonics like methergine, misoprostol
2. Tissue - Ensure there is no retained tissue in the uterus 
3. Trauma - Identify the source of bleeding and address it, especially cervical and vaginal tears
4. Thrombin - review the history of bleeding and consider additional tests like CBC, coagulation tests, clotting test
5. Treatment - Consider IV fluid bolus and uterine tamponade with a foley’s catheter bulb
6. Transfer - to the hospital if need be, monitor vitals closely
3. Perforation
1. Stop the suction, examine the contents of the aspirate for omentum, bowel, products of conception
2. If stable, continue, and complete the procedure under ultrasound guidance. Consider uterotonics and antibiotics. Observe for 1.5-2 hours post-procedure. 
3. If the patient is unstable, transfer 
4. Incomplete abortion
1. Offer misoprostol or 
2. Reaspiration if bleeding, in pain or have signs of infection
5. Accumulation of blood in the uterus post-procedure - patient usually complains of pain, rectal pressure, and this is usually accompanied by hypotension and or vasovagal  syncope
1. Uterine aspiration or uterotonics
6. Endometritis (fever, pain, vaginal discharge, leukocytosis)
1. Antibiotics per the CDC PID regimen
2. Ultrasound +/- aspiration procedure
3. Test for gonorrhea and chlamydia
7. Ectopic Pregnancy  - suspect if POC inadequate at the time
1. Transfer to hospital for treatment with methotrexate vs surgical management

Clinical Significance

Any woman with a positive pregnancy test should be counseled about her options at the time of the consultation in a nonjudgemental manner. Abortion is an overall safe and effective procedure. Providers should be aware of the prevalence of abortion, the restrictions, and the access issues associated with abortion and strive to provide safe care to patients seeking an abortion.

Enhancing Healthcare Team Outcomes

Abortion is safer when the laws regarding abortion are less restrictive and in countries where the gross national income is higher. The stigma associated with abortion is another recognized barrier to accessing safe abortion and can contribute to the maternal mortality rate worldwide. Overall, ensuring women have better access to reproductive health care including modern methods of contraception can ensure the care provided is safe and help reduce maternal and infant mortality rates.