Pregnancy Termination: Indications, Procedures and Challenges

1. Pregnancy Termination:Indications, Procedures and Challenges Michele K. Silverstein, MD, FACOG

2. Overview • Indications for Pregnancy Termination • Methods/Choice of Procedure • Complications

3. Abortion • The termination of a pregnancy after, accompanied by, resulting in or closely followed by the death of an embryo or fetus. Spontaneous expulsion of a human fetus (i.e. miscarriage) • The medical procedure of inducing expulsion of a human fetus to terminate a pregnancy.

4. Induced abortion is one of the most commonly performed gynecologic procedures in the US • <50% done at less than or equal to 8 weeks of gestation • 90% done within the first twelve weeks of gestation • 1% done after 20 weeks of gestation

5. Safety • From a public health perspective, safe and legal abortion services are a cornerstone of maternal health care • The risk of death from abortion at 16 weeks of gestation or less is 5-10 fold less than that of a continuing pregnancy • Maternal mortality in the US is approximately 23 per 100,000 live births

6. Indications for Pregnancy Termination • Elective • Fetal • Maternal • Ectopic location of pregnancy

7. Fetal indications for pregnancy termination • Fetal demise at any gestational age • Diagnosis of genetic abnormality by chorionic villus sampling (CVS) or amniocentesis-chromosomal-inherited genetic disorders • Structural abnormality detected on detailed anatomy ultrasound -i.e. cardiac malformations, anencephaly 3% of all live births affected by a major congenital anomaly

8. Fetal indications for pregnancy termination (2) • Abnormal placentation-placenta previa, accreta, percreta-cesarean scar implantation • Concerns for exposure to teratogens-radiation or other environmental concerns-medications

9. Maternal Indications for Pregnancy Termination • Medical Conditions • Psychosocial Conditions • Cases of rape or incest

10. Considerations of Maternal Disease and Pregnancy • What is the impact of the disease on the pregnancy? • What is the impact of pregnancy on the disease, both short and long term? • What management would be recommended without pregnancy? • Can the change in management be justified? • What are the risks/benefits to the mother and fetus and are they aligned or contrary to each other?

11. Maternal Medical Conditions • Cardiovascular Disease • Surgically Corrected Structural Heart Disease • Chronic Hypertension • Diabetes • Malignancy • Neurologic • Psychiatric • Surgery

12. Psychosocial Factors • Relationship Issues • Other life stressors • Financial • Impact on the family

13. Other Indications • Elective, no medical or other factors considered • Ectopic pregnancy which requires surgery or other medical management

14. Options/Methods of Pregnancy Termination • Choices are gestational age dependent • Surgical • Medical • Expectant (in the cases of fetal demise)

15. Surgical Methods of Pregnancy Termination • Transcervical Evacuation • Dilatation and Curettage (D&C) • Dilatation and Evacuation (D&E) • Major Operations • Hysterotomy • Hysterectomy

16. Dilatation and Curettage • Curettage by vacuum aspiration performed at gestational age of less than or equal to 12 weeks • Technique of Menstrual Extraction can be used in the earliest of cases • Use of a flexible cannula attached to an aspirator or syringe • Manual Vacuum Aspiration (MVA) • Generally does not require cervical dilation • Electric Vacuum Extraction (EVA) more commonly performed • Requires cervical dilation • Use of either local or general anesthesia • Greater than 6 weeks

17. Dilatation and Evacuation • Term used for cervical dilatation followed by evacuation of the products of conception after 12 weeks • Predominant method of termination beyond 12 weeks • Requires a greater degree of cervical dilatation which necessitates the use of osmotic dilators for a period of 6-48 hours prior to the procedure • Tents of Laminaria Japonica, a natural seaweed are the most commonly used dilators • Use of special forceps to remove the larger volumes of tissue • Prostaglandins may also be used for cervical ripening.

18. Major Operations • Rarely Performed • Hysterotomy- a surgical incision in the uterus by a transabdominal approach, in essence, a cesarean section • Hysterectomy • Most commonly performed with abnormal placentation or to complete a failed or complicated D&E

19. Non-surgical Options • Medical Abortion • Induction of Labor

20. Medical Abortion • May be used up to 63 days of gestation, calculated by the LMP or 9 weeks gestational age by sonogram • Most common regimen in the US is mifepristone 200 mg PO followed by buccal administration of 800 mcg of misoprostol 24-48 hours later • Usually causes expulsion of the pregnancy within several hours of the misoprostol dose • Up to 5% require surgical intervention • Increased risk of Clostridial infection • Misoprostol is taken in the privacy of one’s home

21. Induction of Labor • Termination of Pregnancy by stimulation of labor like contractions that cause eventual expulsion of the fetus • Instillation of hypertonic solution of saline or urea into the uterine cavity to cause contractions • More commonly, prostaglandins and/or oxytocin are used • Gestational age dependent • Must be done in a hospital setting

22. Risks and Complications of Pregnancy Termination • Immediate • Delayed • Late • Both medical and surgical methods have risk of complications

23. Immediate Complications • During or within 3 hours of procedure • Uterine perforation (3-20/1000) • Hemorrhage • Cervical injury • Anesthetic Complications • Amniotic Fluid Embolism

24. Delayed Complications • 3 hours to 28 days post-procedure • Infection • Hemorrhage • Failed procedure, retained products of conception

25. Late Complications • Asherman’s Syndrome- Intrauterine Adhesions • Cervical Incompetence • Psychological Effects • Guilt • Depression • Anxiety

26. Abortion is never simple, no matter the state, the stage of pregnancy nor the reason.