Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care

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The chapter is organized as follows:. Some research conducted before is unlikely to reflect the outcomes of how abortions are typically performed in the United States today. As discussed below, for example, the U. Food and Drug Administration FDA -approved protocol for medication abortion was updated in based on extensive research showing improved outcomes with a revised regimen CDER, Techniques used in aspiration procedures are also safer and more effective than in the past.

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Sharp metal curettes, once commonly used, are considered obsolete by many professional groups, and their use is no longer recommended for abortion because of the increased albeit rare risk of injury NAF, a ; RCOG, , ; Roblin, ; SFP, ; WHO, New approaches to cervical preparation and the use of ultrasound guidance have also improved abortion safety Darney and Sweet, ; SFP, This chapter draws primarily on the scientific literature but also includes the recommendations i. Appendix D summarizes the literature search strategies the committee used to identify the relevant evidence, while Table describes the sources of the clinical guidelines cited throughout this report.

When women seek an abortion, they present with a variety of experiences and needs Moore et al. Thus, when women seek an abortion, they should have the opportunity to discuss their questions and concerns and receive support in their decision making. They should also. There is little evidence on how preabortion care is typically provided, but there is consensus among professional guidelines that the preabortion encounter includes the following elements Baker and Beresford, ; NAF, a ; RCOG, ; WHO, :.

Patient education, counseling, and informed consent are overlapping components of preabortion care. Patient education refers to the information women should receive regarding the available treatment options and the risks and benefits of these options Baker and Beresford, It is also integral to the informed consent process—a legal and ethical obligation to all patients defined by state and federal law, malpractice standards, and professional standards ACOG, ; AMA, ; Joint Commission Resources, ; Kinnersley et al. Specific definitions of informed consent may vary from state to state, but the goal of the informed consent process is well established: to ensure that patients understand the nature and risks of the procedure they are considering and that their decision to undergo it is voluntary AAAHC, ; AMA, ; HHS, a ; Joint Commission, The discussion should also include options for analgesia, sedation, or anesthesia, including their associated risks and benefits AANA, ; ASA Committee on Ethics, Not every woman wants or needs psychological counseling in addition to patient education before an abortion Baker and Beresford, ; Baron et al.

Some women may wish to discuss the emotional aspects of the abortion with a counselor Moore et al.

Understanding Early Pregnancy Loss

Women should also be referred to and have access to additional counseling and social services if needed e. As noted in Chapter 1 , most women who undergo abortions are poor or low-income. Three-quarters of abortion patients have family incomes below percent of the federal poverty level Jerman et al. In addition, although the evidence is drawn largely from non-U. Little is known about the extent to which abortion patients receive the follow-up social and psychological supports they need.

A study of Finnish registry data provides some evidence that monitoring for mental health status in a follow-up visit after abortion may help reduce the consequences of serious mental health disorders Gissler et al. Providing evidence-based information on how to prevent a future unintended pregnancy—including the option to obtain contraception contemporaneously with the procedure—is a standard component of abortion care Goodman et al.

Most contraceptive methods can be administered safely immediately after an abortion Fox et al.

Recent studies suggest improved contraceptive use with the placement of implants or the initiation of other contraceptive methods at the time of the abortion or when mifepristone is administered for an early medication abortion Hognert et al. While numerous options for contraception are available, long-acting reversible contraception LARC methods are the most effective for pregnancy prevention ACOG, b ; Winner et al. Further, they are associated with higher rates of continuation, even for adolescents and young women, and fewer repeat abortions compared with other forms of contraception ACOG, b ; Ames and Norman, ; Diedrich et al.

A prospective cohort study of women of reproductive age in the St.

Family Planning | Stanford Health Care

The 10, women who enrolled in the project had the opportunity to obtain the contraceptive method of their choice at no cost in a variety of clinical settings where they received family planning, obstetrical, gynecological, and primary care including two facilities. The study found that offering LARC at the time of enrollment was well received; 75 percent of the 9, participants opted for intrauterine devices IUDs or implants.

LARC users were more likely than non-LARC users to continue using contraception at 12 and 24 months 86 percent versus 55 percent at 12 months, 77 percent versus 41 percent at 24 months. The generalizability of these findings, however, is uncertain given that the contraceptives were free, and the study population included only women who wanted to avoid pregnancy.

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The CHOICE study also evaluated a structured approach to contraceptive counseling and found that counseling could be provided effectively by trained personnel without a medical background Madden et al. Abortion care should always begin with a clinical evaluation, including a pertinent medical history and clinical assessment to assess the presence of comorbidities or contraindications relevant to the procedure.

The primary aim of the evaluation is to confirm an intrauterine pregnancy and determine gestation. The physical exam may involve laboratory tests and ultrasonography to confirm an intrauterine pregnancy; assess gestation; screen for sexually transmitted infections STIs and cervical infections; document Rh status; or evaluate uterine size, position, and possible anomalies ACOG and SFP, ; Goldstein and Reeves, ; Goodman et al.

The contraindications and other circumstances affecting the appropriateness of each abortion method are discussed later in the chapter. Ultrasound is not required, however, and there is no direct evidence that it improves the safety or effectiveness of the abortion Kaneshiro et al. In a study of nearly 4, medication abortion patients aimed at assessing the feasibility and efficacy of foregoing routine use of ultrasound, Bracken and colleagues found that LMP date combined with physical examination was. Medication abortion in early pregnancy is accomplished using mifepristone, a progesterone receptor antagonist that competitively interacts with progesterone at the progesterone receptor site, thereby inhibiting the activity of endogenous or exogenous progesterone.

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This process initiates the breakdown of the endometrium and implanted embryo Borkowski et al. Mifepristone, sold under the brand name Mifeprex, 1 is the only medication specifically approved by the FDA for use in medication abortion Woodcock, Taken orally, it has been shown to increase sensitivity to prostaglandins and is most commonly used in conjunction with misoprostol, a prostaglandin E1 analogue.

Misoprostol causes uterine contractions as well as cervical ripening and can be administered orally, sublingually, buccally, or vaginally. The FDA-approved Mifeprex label states that the drug should not be used for women with confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass; an IUD in place; chronic adrenal.

Danco is the only distributer of Mifeprex in the United States. Buccal medications are placed between the gums and the cheek. Despite the restriction, use of the medication method is increasing, especially in early pregnancy. As noted in Chapter 1 , the percentage of all abortions by medication rose by percent between and and is expected to increase further Jatlaoui et al. In , medication abortions accounted for approximately 45 percent of all U. The current FDA-approved regimen for medication abortion is mg of mifepristone taken orally, followed by mcg of misoprostol taken buccally 24 to 48 hours later FDA, a.

A recent systematic review of this regimen—including 33, medication abortions—found an overall effectiveness rate of The claims are based on a case series report of seven patients who did not receive standardized doses or formulations of the medications i. In a related subsequent systematic review, Grossman and colleagues assessed the likelihood of a pregnancy continuing if the abortion medication regimen is not completed i.

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However, the review found that there were insufficient data to conclude that the progesterone treatment is more likely to lead to continued pregnancy compared with expectant management after mifepristone alone. It is common for medical procedures to result in side effects in addition to the intended outcome. Vaginal bleeding is expected during and after an abortion and occurs in almost all patients during a medication abortion FDA, a.

Bleeding generally starts as the tissue begins to separate from the endometrium and continues for several days after the abortion is complete. The heaviest bleeding occurs during and immediately following the passage of the gestational sac and lasts 1 to 2 days. Some bleeding and spotting may occur up to 9—16 days. Like bleeding, uterine pain and cramping are an expected and normal consequence of medication abortion FDA, a. Cramping can last from a half-day to 3 days Ngo et al.


Ibuprofen—after the onset of cramping—has been shown to reduce both pain and later analgesia use Jackson and Kapp, ; Livshits et al. However, some women still report high levels of pain, and pain is commonly reported as the worst feature of the method. Prophylactic regimens for pain management are an area of active research Dragoman et al.

Other side effects reported by women who undergo medication abortion include nausea, vomiting, weakness, diarrhea, headache, dizziness, fever, and chills Chen and Creinin, ; FDA, a. About 85 percent of patients report at least one of these side effects, and many patients are expected to report more than one FDA, a.

Complications after medication abortion, such as hemorrhage, hospitalization, persistent pain, infection, or prolonged heavy bleeding, are rare—occurring in no more than a fraction of a percent of patients Chen and Creinin, ; FDA, a ; Ireland et al. Obesity i. The Society of Family Planning suggests that medication abortion may be preferable to aspiration abortion when patients, including those with extreme obesity, are at risk of procedural and anesthetic complications SFP, Hemorrhage Prolonged heavy bleeding is rare but may indicate an incomplete abortion 5 or other complications.

Hemorrhage requiring assessment or treatment following medication abortion is also rare. The FDA advises that women contact a health care provider immediately if bleeding after a medication abortion soaks through two thick full-size sanitary pads per hour for two consecutive hours FDA, a. In a study of 11, medication abortions performed in California between and , hemorrhage occurred in 16 cases 0.

The need for a blood transfusion—an uncommon occurrence—is an indication of clinically significant hemorrhage. In a study of more than 1, women receiving medication abortion in Norway, 1 patient required a transfusion 0. Signs and symptoms of serious infection are fever of There is no evidence of a causal relationship between use of mifepristone and misoprostol and an increased risk of infection or death FDA, a ; Woodcock, The incidence of infection in recent studies ranges from 0. The FDA has concluded that the available evidence does not support the use of prophylactic antibiotics for medication abortion CDER, Need for uterine aspiration Some women require a uterine aspiration after medication abortion because of retained products of conception, persistent pain or bleeding, or ongoing pregnancy Chen and Creinin, ; Cleland et al.

Of these, 2. Other recent estimates of the need for an unanticipated uterine aspiration range from 1. There is no direct evidence suggesting that specific types of facilities e.


Indeed, most women in the United States return home after taking mifepristone and take the misoprostol 28 to 48 hours later. As a result, medication abortions occur largely in nonclinical settings. Moreover, as described above, a body of research including systematic reviews Chen and Creinin, ; Kulier et al.