Megan L. Evans and Danielle Roncari
History of present illness
A 19-year-old woman presents after a home pregnancy test returned positive. The patient has been using condoms with her boyfriend for birth control but admits to inconsistent use.
She does not remember when her last menstrual period was and reports her menses are usually irregular. She has occa- sional nausea, but overall feels well. The patient discloses that she is unsure she wants to continue the pregnancy and is interested in hearing her options for an abortion.
Physical exam
General appearance:Well-nourished woman who is nervous
Vital signs:
Temperature: 37.0°C Pulse: 85 beats/min
Blood pressure: 110/76 mmHg
Cardiovascular:Regular, rate, and rhythm Pulmonary:Clear to auscultation bilaterally Abdomen:Soft, nontender, nondistended Pelvic:
Cervix is normal appearing, no discharge or abnormal lesions visualized
Bimanual examination: Shows eight-week size anteverted uterus, no cervical motion tenderness, no adnexal tenderness
Laboratory studies:
Urine hCG: positive Ht: 36.3%
Blood type: A positive
Imaging:Transvaginal ultrasound shows single intrauterine pregnancy with a fetal heart rate in the 150s. The crown–
rump length correlates with a gestational age of eight weeks and three days
How would you counsel this patient?
You inform the patient that she is about eight weeks’pregnant.
You then discuss all of her options for this pregnancy – continuing the pregnancy, adoption, and abortion. She informs you that she is firm in her decision to proceed with an abortion. You confirm that this is her decision and that she is not being coerced into making this decision.
At eight weeks’ gestation, both the medication abortion and surgical abortion options are available to this patient.
You review both procedures and their risks and benefits. After hearing all of her options, your patient elects to have an in-office vacuum aspiration. She likes the privacy and immedi- acy of this option as she is living with roommates and has schoolfinals the following week. Her procedure was uncom- plicated. In discussing contraception, she discloses that she does not desire pregnancy for at least two years and has trouble remembering to take contraceptive pills. She chooses a levo- norgestrel intrauterine device (IUD). You are able to insert an IUD immediately after her procedure.
Epidemiology
Abortion is a common procedure in the United States. Each year, roughly half of all pregnancies in the United States are unintended, and 4 out of 10 of those pregnancies end by abortion [1]. By the time US women reach the age of 45, half have had an unintended pregnancy and one-third have had an abortion [2]. Over 60% of abortions occur before 9 weeks of gestational age, and 88% before 12 weeks of gestational age.
Although late-term abortions are often the focus of restrictive legislation, only 1.5% of abortions occur at 21 weeks’ gesta- tional age or later [1].
More than half of all women who get an abortion are in their twenties, while 18% are teenagers. However, the rate of abortion is highest for women over age 40 (17.5/1000 women).
Thirty-six percent of women who obtain an abortion identify themselves as non-Hispanic white, while 30% and 25% of women identify themselves as non-Hispanic black and His- panic respectively. One-quarter of women have incomes between 100 and 199% of the federal poverty line while 42%
have an income below the poverty line [2].
Like with our patient, the majority of women who have an abortion were using some form of contraception when they became pregnant, most often the oral contraceptive pill or male condoms. Seventy-six percent of pill users and forty- nine percent of condom users reported inconsistent use of these methods at the time of their unplanned pregnancy.
Forty-six percent of women reported not using a contraceptive method when they became pregnant. This group of women perceived themselves at low risk for getting pregnant, had unexpected intercourse, or had concerns about using birth control [3].
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Counseling
Patients whofind themselves with an undesired or unplanned pregnancy often present to their primary care provider or obstetrician/gynecologist for counseling. Patients may be unsure of their options and are looking for guidance and information from their provider. If the provider has a moral objection to abortion or feels unable to provide accurate coun- seling, they should promptly refer the patient to a professional who is capable of counseling on all options.
Additionally, it is important that you, as her provider, and your clinical staffare familiar with your state’s laws on abortion.
For example, some states have parental consent laws, gestational age limits, or waiting periods where women must receive manda- tory counseling at least 24 hours prior to obtaining an abortion.
There are many misconceptions about abortion. As part of the counseling, the provider should make it clear that abortion has not been shown to increase mental health problems, breast cancer, or infertility [4]. The patient should also be reassured about safety of the procedure. Less than 1% of all US patients have a major complication during their abortion. The earlier in the pregnancy that the procedure is performed, the lower the complication risk. Maternal mortality related to abortion is significantly lower than that associated with birth until approximately 20 weeks’ gestation. Overall mortality is 0.567 per 100 000 abortions. This is in contrast to a live birth, which has a maternal mortality rate of 7.06 per 100 000 [5].
Discussion of contraception should also be incorporated into your abortion counseling. Patients should be offered all available methods of contraception for which they are eligible. Side effects, risks, benefits, and effectiveness of each method should be incorporated into this discussion. Long-acting reversible contra- ception (LARC), including IUDs and implants, has been shown to significantly reduce the risk of unintended pregnancy. LARC is safe, effective, and leads to higher contraceptive continuation than other methods. They can be inserted immediately after termination procedures, as done in this patient [6].
Abortion options
Accurate diagnosis of gestational age is necessary to perform either a medication abortion or a surgical abortion. This patient’s gestational age was confirmed by ultrasound. The gestational age of the patient allows her to select either a medication abortion or surgical abortion.
Medication abortion
In the United States, medication abortion is typically offered up to 63 days of gestation with an effectiveness rate of 95–99%;
it is slightly more effective at earlier gestational ages. Some centers have also begun offering medication abortion to 70 days’gestation [7,8].
The most common medication regimen in the United States involves two different medications. Typically, a patient will be given mifepristone, also known as RU-486, followed 24 to 48
hours later by misoprostol to complete the abortion [7]. The most commonly used dose of misoprostol is 800μg. Misoprostol may cause strong uterine contractions, nausea, vomiting, diar- rhea, and a low grade fever. If the regimen is successful, the vast majority of patients will pass the tissue within 24 hours. Alter- natively, in settings where mifepristone is not available, patients can take up to 800μg of misoprostol 24 hours apart to help expel the products of conception. Efficacy for this regimen ranges from 85 to 95% [7]. Risks of medication abortion are rare, but patients should be counseled on the risk of infection, heavy vaginal bleeding, and failure of the regimen or incomplete expul- sion of products with the need for surgical aspiration.
Patients must have a follow-up visit to confirm completion of the abortion. Typical follow-up protocols involve a drop in beta-human chorionic gonadotropin (beta-hCG) levels of greater than 80% from the start of the procedure or an ultrasound [9]. Ongoing research is being done looking at alternative methods of follow-up. For patients with an ongoing pregnancy or retained pregnancy tissue, additional medication or instrumentation is typically offered.
Surgical abortion
The patient may also elect to have a surgical abortion. This procedure can be done in a clinic setting or in the operating room and is 98–99% effective in removing all products of conception. In thefirst trimester, the procedure can be done using either a handheld manual vacuum aspirator or electric suction. Some clinical settings may provide moderate sedation or general anesthesia; however, this procedure can be done safely and comfortably under local anesthesia with a paracer- vical block. Risks of the procedure are rare but include bleeding, infection, uterine perforation, retained products of conception, ongoing pregnancy, and cervical injury.
Prior to the procedure, it is important to confirm gesta- tional age. If there is any uncertainty, the patient should have an ultrasound. A bimanual examination to confirm the uterine size and position should be performed. Accurate assessment of uterine size and position is essential in choosing the appropri- ate instruments and guiding the direction of instruments into the uterine canal. This assessment also helps to decrease com- plications during the procedure.
Either the manual vacuum aspirator or electric suction can be used to complete the procedure and usually requires only two or three passes into the uterine cavity to completely empty the uterus of all products. Rarely is a sharp curette needed to confirm all products of conception have been removed from the uterine cavity.
This manual vacuum aspirator or electric suction can also be used for missed or incomplete abortions, treatment of hemato- metra, endometrial sampling, and failed medication abortion.
Abortion providers
Although abortion is a legal procedure, the number of abor- tion providers has decreased in the United States. Between
Case 32: Undesired pregnancy in a 19-year-old woman
1982 and 2005, the number of providers decreased by 38% and has recently reached a plateau. Unfortunately, 87% of US counties do not have an abortion provider and 35% of women between the ages of 15 and 44 live in those counties [10].
Sixteen percent of women have to travel between 50 and 100 miles to obtain abortion services, and an additional 8% of women have to travel greater than 100 miles [11]. Addition- ally, 80% of abortion clinics have reported at least one form of harassment, picketing being the most common [11].
Key teaching points
Half of all pregnancies in the United States are unintended and 40% of those pregnancies will end by abortion. Of the
women who reach the age of 45, one-third will have had an abortion.
Most patients who seek abortions are between the ages of 21 and 24, are using contraception at the time of
pregnancy, are already mothers, are living in poverty, and have a religious affiliation.
Abortion is a safe and legal procedure; however, it is safer with earlier gestational ages.
Patients below nine weeks’gestational age have the option for either a medication abortion or a surgical abortion.
Abortion has not been linked to breast cancer, infertility, or mental health problems.
References
1. Finer LB, Zolna MR. Unintended pregnancy in the United States:
incidence and disparities.Contraception 2011;84:478–85.
2. Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion.
Obstet Gynecol2011;117:1358–66.
3. Jones RK, Darroch JE, Henshaw SK.
Contraceptive use among US women having abortions in 2000–2001.Perspect Sex Reprod Health2002;34:294–303.
4. American College of Obstetricians and Gynecologists.Induced abortion and breast cancer risk. Committee Opinion
No. 434.Obstet Gynecol2009;113:
1417–18.
5. Grimes DA. Estimation of pregnancy- related mortality risk by pregnancy outcome, United States, 1991 to 1999.
Am J Obstet Gynecol2006;194:92–4.
6. American College of Obstetricians and Gynecologists. Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121.Obstet Gynecol2011;118:
184–96.
7. American College of Obstetricians and Gynecologists. Medical management of abortion. ACOG Practice Bulletin No. 67.Obstet Gynecol2005;106:
871–82.
8. WinikoffB, Dzuba IG, Chong E, et al.
Extending outpatient medical abortion services through 70 days of gestational age.Obstet Gynecol2012;120:1070–6.
9. Grossman D, Grindlay K. Alternatives to ultrasound for follow-up after medication abortion: a systematic review.Contraception2011;83:
504–10.
10. Jones RK, Kooistra K. Abortion incidence and access to services in the United States, 2008.Perspect Sex Reprod Health2011;43:41–50.
11. Henshaw SK, Finer LB. The
accessibility of abortion services in the United States, 2001.Perspect Sex Reprod Health2003;35:16–24.