A woman is fertile for about 30 years of her life. If she has a normal reproductive system, becomes sexually active in her teens, and uses no contraception, she could have more than a dozen children. As a result, for most of her reproductive years the average woman is trying either to postpone or to avoid pregnancy.
More than half the 6 million pregnancies that occur in the United States each year are not intended. Of these mistimed or unwanted pregnancies, about 1.5 million are ended by an induced abortion. By the time they reach menopause, two-thirds of American women have had at least one unintended pregnancy, and many have had an abortion. Women who have abortions come from all religious, socioeconomic, and ethnic backgrounds.
According to researchers at the Alan Guttmacher Institute, 47 percent of all unwanted pregnancies happen to couples who practice birth control. The very small percentage (10 percent) of men and women who do not use contraceptives account for the remaining 53 percent of unintended pregnancies.
Almost all induced abortions in the United States take place between the 7th and 13th weeks of pregnancy (counting from the first day of the last menstrual period), which is in the first trimester
(3 months) of a pregnancy. Surgical abortions are not usually performed before the 6th week because the embryo is too small to find easily. The safest time to have a surgical abortion is before the 8th week. A first trimester medical abortion, a new technology using drugs instead of surgery, is usually performed before the end of the 8th week (before the 56th day of pregnancy).
The surgical method used most frequently for first trimester abortions is vacuum aspiration, also called suction curettage. Current medical alternatives use either mifepristone (formerly known as RU486) or methotrexate. Both are combined with misoprostol, a prostaglandin.
After the 13th week, a pregnancy is in its second trimester and the method used to end a pregnancy at this stage is dilation and evacuation. As each week of pregnancy passes, the risk of complications from an abortion increases and so does the cost. Abortions after 20 weeks usually are performed only if the fetus has a severe malformation or when it is necessary to save the life or health of the mother (Figure 18.1).
Although some abortions are performed in hospitals, most are carried out in clinics as outpatient procedures. The majority of clinics limit their services to the early months of pregnancy. (Only
6 or less
Weeks of pregnancy
FIGURE 18.1 Serious Complications for Every 10,000 Abortions Source: Stewart, Guest, et al. (1987).
IN A NUTSHELL
Today, both surgical and medical abortions are available. Surgical abortions most often use a suction technique to empty the uterus. Medical abortions use pills to make the uterus empty itself.
Surgical abortions take less time and at this time are still easier to obtain. Medical abortions are only available for very early pregnancy. They cause cramps and you will observe more bleeding. Both types are safe.
If you are considering an abortion, it is important not to delay. The earlier it is done, the easier it is and there is less chance of complications. Later abortions take longer and may require a hospital stay.
If you need help in getting a pregnancy test or finding a clinic that performs abortions, call the National Abortion Federation hotline: 800-772-9100.
25 percent of abortion providers perform such surgery after the 16th week of pregnancy.)
In the late 1980s, the office of the Surgeon General, having reviewed more than 250 studies, found no support for claims that legal abortion causes women emotional damage. They did note, however, that a woman's distress is greatest before an abortion and that most women reported feeling relieved and calm afterward, especially following a first trimester abortion.
Legal abortions are safe: the mortality rate for surgical abortions has remained at less than 1 death per 100,000 abortion procedures through the 1980s, according to the U.S. Centers for Disease Control.
You should start looking for an abortion provider right away if you think you may need an abortion. In large cities, this usually is not difficult, but in many states there may be only one source—or none at all. The quickest way to find help may be the National Abortion Federation hotline: 800772-9100.
The First Step: A Pregnancy Test
You can find out if you are pregnant by testing yourself at home with a kit that can be bought at most drugstores. These tests are reliable if you follow the directions carefully. If the test is negative but you still do not have your period, you need a professional test. In fact, a good first step is to go to a clinic or a doctor for a pregnancy test and to do this as soon as you suspect you are pregnant. It is inexpensive, and the people you talk to are not likely to be judgmental.
The early laboratory test for determining pregnancy—a blood test—is so sensitive it can detect the very low levels of the pregnancy hormone, human chorionic gonadotropin, in your blood as early as 7, 8, or 9 days after fertilization. (The old standard urine test cannot confirm a pregnancy until 28 days after ovulation, when a menstrual period is about two weeks overdue.)
In addition to the blood test results, a pelvic examination is
PREGNANCY TESTS AND ABORTION: PROTECTING YOUR PRIVACY
If you are considered legally underage in your state (which usually means 18 years or younger), and you want to talk to a clinic about an abortion or having a pregnancy test, and are worried about privacy, here are some questions to ask. Some of these questions also are useful if you want a contraceptive method that requires the services of a clinic or doctor (the Pill, Norplant, Depo-Provera, a diaphragm, or cervical cap).
• Do you take care of people who are under 18 years old?
• Do my parents or another adult have to come with me?
• Do I need my parents' or another adult's permission to have (a pregnancy test), (an abortion), (this method of birth control)?
• Who will get the results of my pregnancy test? When will the results be ready?
• Will a bill for a pregnancy test be sent in the mail to my home? Can I pay for it in cash?
• If I want an abortion and the law says my parents or another adult must be informed, will you help me talk to them or find an alternative through the court system?
• Do you have someone who can answer my questions?
• Can I come back more than once to talk to someone about having an abortion? (Get as much counseling as you need.)
Antiabortion groups may advertise in the Yellow Pages and elsewhere as family planning centers or even abortion providers or counselors. Their staff will try to discourage you from terminating your pregnancy and may deliberately delay you until it is late to obtain an abortion. Make certain the clinic you contact actually performs abortions before you make an appointment.
necessary to confirm the results and to estimate how far along the pregnancy is. Whether you are considering an abortion or will continue with your pregnancy, an accurate dating of the pregnancy is important. If your physician cannot determine how far advanced the gestation is, an ultrasound evaluation may be necessary. As early as 6 weeks after your last normal period, ultrasound can reveal a pregnancy sac inside your uterus, making it possible to know how long you have been pregnant.
Even with the early test, the window of time available for making a decision about a pregnancy is small. Most women realize they are pregnant at about six weeks. Because abortion is easier, safer, and much less expensive when done in the first trimester, this does not allow much time for assessing your feelings about having a baby, about your partner, and about your life situation.
The best place to get a pregnancy test is from a physician or clinic that can also provide you with objective counseling and help you carry out whatever decision you make about continuing the pregnancy. Good family planning clinics and doctors offer information on abortion, or where to go for prenatal care and, if you wish, adoption procedures. If the test shows that you are not pregnant, this type of clinic or health care provider can help you find a dependable method of birth control. Wherever you go for a pregnancy test, make sure it is understood that you need an immediate appointment to verify a pregnancy. If you will have to wait more than a few days for an appointment, find another doctor or clinic.
Because it is so important not to put off getting a pregnancy test, if you do not have ready access to a clinic that provides a range of family planning services, obtain a pregnancy test from your family doctor or your gynecologist. Although you own doctor may not perform abortions, a pregnancy test is a routine lab procedure. If you ask, the doctor may also help you find a reputable provider of family planning services that include abortion.
If you do not have a doctor and there is no Planned Parenthood clinic, the county health department or a nearby hospital may offer pregnancy testing, abortions, or information on clinics that provide abortions. In some cities, there may be an independent laboratory that offers pregnancy testing.
Freestanding clinics are the most common providers of abortion services. Because many abortions are performed in these facilities, the attending physicians are extremely skilled in the procedures. One of their rules is that you must make your own decision about your pregnancy without any outside pressure. They believe they chiefly should offer objective and nonjudgmental information and counseling about your available options.
Not every community has a facility that offers abortion services. To find sources of abortion care elsewhere, start with your family doctor or gynecologist. Even if your doctor is uncomfortable doing abortions, he or she may (or may not) be willing to refer you to a surgeon or clinic that offers counseling and abortion care.
At colleges and universities, nursing personnel at the infirmary or the health service may be knowledgeable about pregnancy testing and what options are available. Just how much assistance they can provide, however, varies from school to school.
Planned Parenthood clinics are the most reliable sources of reproductive health services that include abortion. They will be listed in the white pages of the telephone directory. If there isn't one in your community, state or county health departments, departments of social services, or the Visiting Nurse Association traditionally provide the names of family planning clinics or medical practices that include abortion among their health care services. The departments of obstetrics and gynecology at most nondenominational hos-
An important resource is the National Abortion Federation (NAF), which operates a nationwide abortion hotline. By calling 800-772-9100 (tollfree), you can get answers to questions about abortion regulations in your state, the names of the nearest clinics that provide abortion services, including medical abortions, and suggestions on where to obtain financial help. (In Washington, D.C., the NAF number for abortion information is a local number, 202-667-5881.) The NAF will give out only the names of its affiliated clinics, which maintain high standards for care and counseling.
pitals may know of the nearest clinics that offer skilled abortion services. You can also try the Yellow Pages under "Clinics," "Abortion," or "Family Planning Information Centers." Finding help may not be easy, but it can be done if you are persistent and resourceful.
The majority of U.S. counties do not have a facility that offers surgical abortions. If clinics or doctors in your area do not provide abortion services, call telephone information for the number of the Planned Parenthood affiliate in the nearest large city. Planned Parenthood clinics offer a broad range of family planning services, including abortion referrals. All their clinics must meet the organization's high standards for care and counseling, and some offer abortions.
Do not delay your search for good-quality abortion services, but do not act in a panic, either. If it appears that you will have to travel to another community or even to another state to obtain care, be certain that you are pregnant before you make your arrangements. Knowing how far the pregnancy has advanced gives you some idea of what procedures you will need—not all clinics offer second trimester procedures, for example—and this information will help you choose an appropriate clinic.
Although abortion is legal in the United States, each state has laws that regulate it. These laws may require a waiting period, an informed consent procedure, or the consent of parents if you are a minor. Many states restrict the availability of abortion or where it can be done when pregnancies have advanced beyond certain weeks. The National Abortion Federation hotline is the best source of information about restrictions in your state.
As with any other facility that offers health care, a clinic or surgeon providing abortion services should meet certain standards. Ask questions when you visit the clinic or doctor for the first time. Questions to ask include:
• Do they have a written agreement with a nearby hospital to provide backup emergency care if necessary? How many minutes away by car or ambulance is the hospital? (It should be within a 10 to 20 minute drive, preferably closer.) Do clinic physicians have admitting privileges at that hospital? Does the clinic have the capability of transferring a patient to the hospital?
• Are private spaces set aside in the clinic for talking with clients? Is printed information available on fees and on the availability of public assistance or other funds? Does the information on fees itemize the services included in the basic fee, and does it list the additional services that might be needed and their costs?
• Is the recovery room supervised at all times by either a licensed nurse or a physician who is on the premises?
• Does the facility have on hand a "crash cart"—the utility cart that holds the equipment for providing cardiac and pulmonary resuscitation? Is at least one staff person on each shift trained in cardiopulmonary resuscitation (CPR)?
• Is the operating room large enough to hold several people as well as the equipment? Is it well-lighted? (Ask to see it.)
• Is there an adequate supply of intravenous solutions and at least six units of plasma volume expander available for emergency use? (The expander is used as a blood substitute to maintain blood pressure in case of hemorrhage.)
• Is there a sterilizing facility for the instruments?
• Does the clinic routinely send aborted tissue to a pathology laboratory to confirm that pregnancy tissue was indeed removed, if it cannot be identified visually? (A positive result means the pregnancy was in the uterus and is not an ectopic pregnancy still growing in a fallopian tube or some other place outside the uterus, where it could rupture.)
• If this is a second trimester abortion, is diagnostic ultrasound available? An examination by ultrasound is recommended before any second trimester pregnancy is terminated. After the 14th week, the National Abortion Federation requires that its member clinics perform an ultrasound examination for an exact determination of fetal size and position. Some states also may require this of abortion facilities.
With the availability of vacuum aspiration (suction) equipment, there is no need today for surgeons to perform first trimester abortions with a sharp curette, and few do. Because some physicians may still use this method, however, it is a worthwhile precaution to ask the doctor what method he or she uses. With a suction curette, pain and bleeding are reduced and the risk of leaving pregnancy tissue behind is decreased. Some clinics now offer a medical abortion, which uses drugs instead of surgery, as well.
Although the procedure before an abortion varies from clinic to clinic or surgeon to surgeon, in general it should cover the same points. A medical assistant or counselor will answer your questions and work with you to determine whether you need more information or other help in deciding what to do. She or he will want to make certain that you have considered all your options and are comfortable with your decision. If the clinic offers medical abortions, this method will be described so you can make an informed choice about which approach you may prefer. Together you will go over the lengthy informed consent document you must sign before the abortion can take place. The counselor should be able to answer all your questions about the clinic's emergency preparations and facilities, about the procedures, and what happens afterward. As most counselors will tell you, at any point before the abortion actually gets under way, you can change your mind.
The counselor or medical assistant will take your medical history. You will be asked about any allergies to local anesthetics, antibiotics, common pain relievers, and other drugs. You also will be asked about current illnesses or conditions that might affect the performance of the abortion.
If you have decided to have an abortion, an appointment will be made for the procedure, and several tests will be performed, including:
• A blood or urine pregnancy test.
• A blood count to check for anemia.
• A blood test to determine if you are Rh negative. If you are, you will be given Rh immune globulin after the abortion to avoid the risk of Rh sensitization, which could have an adverse effect on a later pregnancy. (This procedure is done for every pregnancy, whether carried to full term or not.)
• Clinic rules may require that you be tested for gonorrhea, syphilis, chlamydia, or the AIDS virus. If you have an active STD, the clinic is likely to treat the disease before scheduling your abortion, so that the abortion procedure does not spread it to the upper part of your reproductive system. In addition, some clinics test for sickle cell disease and cancers of the reproductive tract.
If you are having a surgical abortion and are allergic to the lidocaine family of local anesthetics, general anesthesia may be advised. General anesthesia might also be preferable if you have any problem that makes it difficult for you to be calm and cooperative when surgery is performed with a local anesthetic. If you have any medical condition that might increase the risk of complications during the procedure, the clinic may suggest that a hospital is a better place for having the abortion. Such a condition might be a bleeding disorder, severe asthma, heart disease, severe diabetes, or epilepsy that is not well controlled.
At most clinics you will receive instructions about what to do to prepare for the abortion. You will be given pregnancy and blood tests, and a brief physical. If the clinic uses osmotic dilators to help open the cervix, these are inserted the day before the procedure. Osmotic dilators are short, slender, and made of a highly absorbent material. As they absorb moisture, they gradually expand, gently enlarging the cervical opening. They are put in while you lie in the usual position for a pelvic exam. Because some cramping can occur during the insertion, a local anesthetic may be injected. Without such anesthetic some women have no discomfort, while others experience mild cramps. In the rare event that you have severe pain or bleeding after the dilators are in place, call the clinic or the doctor who will be doing the abortion.
You will be given instructions about how long to avoid food and drink before the surgery, depending on the type of anesthesia that will be used.
Take a shower or bath just before you leave for the clinic. Arrange to have a friend or relative who knows about your pregnancy go with you to provide emotional support and to take you home. You will be at the facility for several hours and much of that time may be spent waiting, so you may also want to bring something to read or to do. After the abortion, if your friend cannot drive you home, plan to take a taxi.
At the clinic, the physician who is going to perform the procedure will conduct a brief examination, which includes checking the size and position of the uterus to determine again the size and length of the pregnancy. As we have said, if your pregnancy is over 14 weeks, many clinics do an ultrasound check to confirm the size of the fetus. Some clinics perform ultrasound whenever the pregnancy is thought to be over 12 weeks.
The abortion technique used will depend on the length of the pregnancy. In the first 3 months, a suction or "vacuum" method is used; a pregnancy between 3 and 6 months requires a dilation and evacuation procedure; later abortions are rare and are special cases that require special treatment.
The first trimester of a pregnancy is the first 3 months—12 to 13 weeks—counting from the first day of your last menstrual period. The most commonly used method of abortion during this period is the vacuum aspiration method, also called vacuum curettage or suction curettage. (Curettage means "scraping out," aspiration is "removal by suction.") Vacuum aspiration is similar to the method used by dentists to remove saliva and blood from your mouth. It safely and effectively empties the uterus through the opening in the cervix.
Although occasionally there are medical or psychological reasons to use general anesthesia, a vacuum aspiration most often is carried out with a local anesthetic. It can be performed in various outpatient settings: clinics, private medical offices, surgicenters, or hospital outpatient centers.
The cervix must be dilated to approximately one-half inch in diameter in order to insert the vacuum tube (cannula). For an early abortion, the tube is about the diameter of a drinking straw. The opening in the cervix can be enlarged with a metal dilator at the time of the surgery or by using an osmotic dilator beforehand, as described above.
At the time of the abortion itself, a speculum is placed in the vagina and the cervix is disinfected. A speculum is made of metal and looks like a bit like a duck's bill. It is designed to spread and hold open the vagina so the cervix can be seen. It seldom causes pain, although it is not very comfortable. Pain-carrying nerves are made numb next with injections of lidocaine or a similar anesthetic. Because the cervix has widely spaced nerve receptors, you may not feel the injection at all, although it sometimes can set off cramps that usually pass quickly.
After the anesthetic has taken effect, the physician gently grasps the cervix with an instrument called a tenaculum and, if necessary, dilates it further until it is open enough to accept the suction tube. The duration of the pregnancy determines the size of the tube—more advanced pregnancies require a larger tube. The tube is connected by a hose to an electric vacuum pump, like those used by dentists. If the pregnancy is less than nine weeks, some clinics simply use a large syringe for suctioning.
During the aspiration, the tube is moved around inside the uterus to loosen and remove the pregnancy sac and the thickened lining of the uterus. This takes a few minutes; more advanced pregnancies will require more time. The tube is removed, and the inside of the uterus is gently explored with a curette, a loop-shaped instrument with sharp edges, to make sure all the tissue has been removed. The suctioning takes 3-5 minutes and the entire process requires 10 to 15 minutes.
Discomfort or pain caused by the vacuum procedure varies. Some women feel almost nothing; others find it quite uncomfortable. Toward the end, when most of the tissue has been removed, the uterus contracts. This causes cramps that can range from mild to severe. Fortunately, they seldom last for more than an hour and can be relieved by medication. Most women feel well enough to walk out of the procedure room. Besides cramping, it is not unusual to have some vaginal bleeding and nausea afterward; nevertheless, most women feel ready to go home within an hour or so.
If you have had an outpatient procedure, you should not be discharged until you have recovered satisfactorily. While you are still in the recovery room, the attending nurse or doctor should check your pulse, blood pressure, how much vaginal bleeding you are having, and your general physical condition. If a general anesthesia was used, you should be fully alert before you are discharged. Before you leave, make an appointment for a followup examination. Also get an emergency telephone number in case a complication develops after the clinic or office closes.
You may feel like returning to your usual level of activity immediately, or you may want to take it easy. Generally speaking, it is a
Immediately contact your surgeon or the clinic where you received your abortion, or go to the nearest hospital emergency room, if you experience these symptoms:
• a temperature over 100.4 degrees Fahrenheit;
• chills, fatigue, or overall aching feeling;
• cramps or abdominal pain that steadily worsens;
• an abdomen that feels tender or painful when touched or when you cough, sneeze, walk, or jump;
• bleeding that lasts more than 3 weeks, or bleeding that for 3 days is more than your usual, heaviest, menstrual flow;
• unusual or bad-smelling vaginal discharge; or
• pregnancy signs that do not disappear.
good idea to avoid strenuous exercise for at least a few days. Showering immediately after the abortion is all right, but do not take a bath for several days to avoid the risk of introducing bacteria into the uterus.
Expect some cramps and vaginal bleeding during the next weeks. It is normal for light bleeding or spotting or just brownish discharge to occur off and on for as long as a month afterward. If the bleeding is heavy—if you are soaking more than one sanitary pad an hour and/or passing clots larger than a half dollar—and it lasts for more than 1 or 2 days, call the clinic or physician who performed the abortion.
The cramps that usually follow an abortion almost always respond to over-the-counter pain relievers. A non-aspirin product is a better choice because it does not interfere with blood clotting. The standard dose of two tablets every 3 or 4 hours usually provides relief. If your cramps are so severe that this does not help, or if the pain becomes steadily worse, call your clinic or doctor.
The drug methergine may be prescribed during the first 24 to 48 hours after the abortion to encourage firm uterine contractions and limit the amount of bleeding. If this results in severe cramps or pain that spreads downward to your thighs, call your practitioner. To ease the cramps it may be necessary to stop taking the drug.
Because infection is possible after a surgical abortion, take your temperature if you have chills or feel feverish. If you are taking a pain reliever such as acetaminophen, take your temperature before you take the pills, because they lower body temperature. If you have a temperature over 100.4 degrees F, call your physician or the clinic.
Do not use tampons (use sanitary pads), douche, or have intercourse for 2 weeks after the abortion to avoid the possibility of infection. If you have had a late (second trimester) abortion, you may develop breast milk. To stop it, wear a snug-fitting bra day and night for 2 or 3 days. Avoid any stimulation of the nipples and do not squeeze the milk from your breasts, since this increases milk production.
The second trimester is the second three-month period of a preg-nancy—between 14 and 26 weeks of gestation. Ending a pregnancy after 14 or 15 weeks is more complicated because the fetus is larger and there is a greater blood supply to the uterus. Only about 10 percent of abortions in the U.S. are carried out in the second trimester, and most are done during the first few weeks of this period.
The procedure most commonly used at this stage of a pregnancy is called dilatation and evacuation, or D&E. The cervix must be dilated to a greater degree—to more than half an inch—because the fetus is larger. Dilating the cervix may take more time, and the abortion itself takes longer. This technique is preferred for pregnancies that are between 13 and 16 weeks, and very skilled surgeons may use it for pregnancies that are up to 20 weeks or even longer. It is safer than an instillation abortion, which can also be used for second trimester pregnancies. Like vacuum aspiration, a D&E can be performed in outpatient settings, as long as there is hospital backup readily available. If it is carried out later in this trimester, it is often done in a hospital.
Having a D&E is much like having a vacuum aspiration, although with an increased risk of complications. If local anesthesia is used, the amount of discomfort and the sensations are very similar, and the recovery time is about the same. If general anesthesia is used, there is no pain or discomfort, but the recovery time generally is longer.
In these later abortions, osmotic dilators generally are used to open the cervical canal. At the time of the procedure, after the anesthetic has taken effect, such dilators are removed and, if necessary, the cervical canal is expanded further with a surgical dilator.
In a D&E, a larger vacuum tube is necessary. It is used in combination with a forceps and other instruments that break up pieces of tissue and remove anything that cannot be suctioned out. To minimize blood loss, surgeons may use drugs to encourage the uterus to tighten up or contract. A dilation and evacuation takes 20 to 30 minutes. It is the safest method for ending a second trimester pregnancy and is used for the majority of these advanced pregnancies.
Instillation Abortion. A long, hollow needle is inserted through the abdominal wall and into the liquid-filled amniotic sac surrounding the fetus. A solution of salt or prostaglandin hormones is slowly instilled through the needle into the pregnancy (amniotic) sac. These can be combined or used alone to induce labor so the fetus and placenta are expelled. Until the 1970s, instillation abortion was the most common method for terminating second trimester pregnancies. Today it has been largely replaced by the safer and much shorter D&E.
An instillation abortion is almost always done in a hospital and can require 1 or 2 days of hospitalization. Osmotic dilators are sometimes inserted beforehand to help open the cervix. After the instillation, there is usually a wait of several hours or more before labor starts. Labor can be long and painful and generous amounts of pain medication may be needed.
After the fetus and placenta are expelled, pain and discomfort usually subside. If the placenta is not expelled completely, a D&C (dilatation and curettage) may be necessary. After an hour or two of rest, many women feel well enough to shower. Most hospitals require that women who have this procedure remain at least 3 to 4 hours afterwards for observation.
Hysterotomy. Hysterotomy is a major operation, somewhat like a mini-cesarean section, that requires general or epidural anesthesia. (Epidural is an injection into the epidural area of the middle/lower back.) A hysterotomy has a higher complication rate (and thus a higher death rate) than other methods. Moreover, any future pregnancies carried to term may require a cesarean delivery, because a hysterotomy incision is thought to weaken the uterus wall. (Unlike a true cesarean section, the incision is made in the upper part of the uterus, where it is more likely to rupture during another labor.) Hysterotomies were used for second trimester abortions during the brief period right after abortions were made legal everywhere in the United States and before other methods became readily available. Today they are limited to the extremely rare second trimester cases in which a woman has a uterus so seriously malformed that a D&E would be dangerous.
Hysterectomy. Hysterectomy, the removal of the uterus itself, also is a major surgery that requires an epidural or general anesthesia. It, too, carries a substantial risk of complications and a higher mortality risk. Today a hysterectomy is considered inappropriate for abortion and should be performed only when no other procedure is possible.
Menstrual Extraction. Not strictly an abortion method, in menstrual extraction a syringe was used to remove the contents of the uterus when a woman feared she was pregnant, such as after a missed menstrual period or rape, without waiting for a urine test to confirm this. Menstrual extraction was used before the availability of the blood test that can detect a pregnancy as early as 8 days after conception. With the development of this test and the increasing availability of emergency contraception, menstrual extraction is no longer needed.
Before 1973, when abortion became legal in the United States many women died or had serious medical problems after attempting to induce their own abortions or by going to untrained practitioners who performed abortions with primitive instruments or in unsanitary conditions. Women ended up in emergency rooms with serious complications: perforations of the uterus, retained placentas, severe bleeding, cervical wounds, rampant infections, shock, and gangrene.
Today, serious complications from abortions done during the first trimester are unusual. Of the 3 percent of women who have complications, 2.5 percent have minor complications that can be handled in the physician's office or at the clinic. Approximately 0.5 percent require an additional surgical procedure and/or hospitalization.
Complication rates are somewhat higher for abortions performed between 13 and 24 weeks. General anesthesia, if it is used, also carries a risk. In addition to the length of the pregnancy, important factors that affect the possibility of complications include the skill and training of the practitioner, the kind of anesthesia used, the woman's health, and the method used.
Hemorrhage. The most common complication immediately after an abortion is excessive bleeding. Of every 1,000 women who have abortions, between 2 and 10 have profuse bleeding. A very small percentage bleed so severely they need a transfusion. Excessive bleeding occurs when the uterus is not completely cleared of pregnancy tissue or when it does not tighten up enough afterwards. Bleeding also can occur if the uterus, cervix, or vagina have been injured. Heavy bleeding usually is prevented by using a drug to encourage the uterus to contract (its contraction closes the blood vessels) and by using a local rather than a general anesthetic. General anesthesia appears to reduce the strength of uterine contractions and is associated with greater blood loss. Making sure all the placenta has been expelled or removed from the uterus also helps prevent blood loss. It is especially important that this be done thoroughly in a second trimester abortion, when the uterus is bigger and tissue is more apt to be overlooked.
Substantial blood loss also can occur if a blood vessel has been cut or damaged accidentally during the procedure. If the blood loss is not great and the tear (in the cervix, for example) can be repaired with stitches, the abortion can be completed. If the injury is severe, it is best dealt with in a hospital. A transfusion may be necessary and exploratory surgery or laparoscopy may be needed to determine the extent of the damage.
In fewer than 1 percent of cases, blood clots can accumulate in the uterus, requiring another suctioning procedure. If you have a bleeding disorder or are taking medication that may slow blood clotting, you are at greater risk of hemorrhage.
Incomplete Abortion. An abortion is not complete if any tissue remains in the uterus. Most obvious indications of an unfinished abortion are cramps and bleeding. If you continue to experience signs of pregnancy—nausea, breast tenderness, and fatigue—seek treatment.
In some instances of incomplete abortion, however, you may have no signs of pregnancy or any other indications that the abortion was not thoroughly done. For this reason, it is important to see your surgeon for your post-abortion examination, which generally is scheduled when you have your abortion. If it will be difficult to return to the clinic where you had the abortion, arrange to have this checkup performed by a local doctor or other health care provider.
Infection. Cramps, pain that gets worse, fever, a smelly vaginal discharge, pelvic discomfort, and feeling unwell may be signs of an infection in the uterus or fallopian tubes. The presence of tissue fragments in the uterus increases the risk of infection.
If you suspect an infection, seek medical care at once. Most infections respond well to antibiotics if they are caught early. An infection that becomes severe can require hospitalization and vigorous treatment with intravenous antibiotics. Infections of the uterus and fallopian tubes may cause scar tissue and adhesions to form, making it difficult or impossible to become pregnant in the future. Severe infections can necessitate a hysterectomy and the loss of the uterus, fallopian tubes, and ovaries.
To avoid this risk, many clinics routinely provide an antibiotic just before or for 1 or 2 days after the abortion. Women at risk for pelvic inflammatory disease may be given antibiotics longer. In addition, antibiotics are often prescribed beforehand for women with a heart valve disorder, an artificial heart valve, or another congenital heart abnormality. If you have one of these problems, discuss the use of antibiotics with the surgeon performing the abortion and, if possible, your heart specialist.
Injuries to the Uterus, Cervix, or Nearby Organs. In rare instances (fewer than 1 percent), the cervix is torn during the abortion and may require stitches. Such injuries are less likely to occur when laminaria are used to dilate the cervix. The wall of the uterus (or other organs) can be injured by an instrument. Simple puncture wounds are likely to close up and heal themselves, but if the instrument goes through the wall and damages other structures, emergency surgery may be required.
Drug Reactions and Other Adverse Effects. A reaction can be caused by the Novocain-like local anesthetics that may be used, by antibiotics, or by the drugs used for encouraging contractions.
In an instillation abortion, the saline solution can be injected accidentally into a blood vessel, causing death. Also, a blood vessel or the uterus can be injured by the needle. If saline mistakenly is injected into muscle, it may destroy the tissue in the immediate area.
Long-Term Complications. Abortions using suction, which are carried out early in the first trimester, appear to have no negative effects on a woman's future reproductive health. Such vacuum aspiration abortions do not increase the chance of having a miscarriage (spontaneous abortion), a premature birth, or a low-birth-weight baby in the future. Fertility also is not affected by an abortion that is carefully performed, especially when it is done soon after conception.
Complications after an abortion, however, especially an infection, can lead to infertility. Injuries to the cervix that occur during an abortion (or childbirth) can increase the chance of developing cervical problems during a future pregnancy. Such an injury may cause the cervical canal to weaken and open under the pressure of the growing fetus, causing a spontaneous abortion. Generally, this can be treated successfully.
A medical abortion has the advantage of avoiding the complications that can arise from surgery and anesthesia. Although many women feel more comfortable with it, it requires one more clinic visit and the process takes longer than a surgical procedure.
The National Abortion Federation hotline (800-772-9100) can provide you with information on the nearest clinic or physician offering medical abortions.
Mifepristone (formerly known as RU486) with Misoprostol
The most commonly used drug combination for terminating early pregnancy worldwide is mifepristone plus misoprostol. Mifepristone blocks the action of progesterone and the maintenance of the implanted embryo. The embryo dies and is expelled by the uterus. This method works best during the early weeks of pregnancy. Later on, the placenta produces too much progesterone for mifepristone to counteract it effectively. Misoprostol is a prostaglandin that is a standard treatment for preventing gastric ulcers caused by the use of nonsteroidal anti-inflammatory medicines (such as aspirin and ibuprofen). It also causes the uterus to contract.
When used alone, mifepristone is 65 to 80 percent effective in terminating an early pregnancy. When it is combined with prostag-landin, the success rates for early first trimester abortions have exceeded 95 percent. Mifepristone combined with a prostaglandin has been used for abortions in France, Great Britain, China, Sweden, and other countries, and more than 350,000 women now have chosen this method.
In the United States, clinical trials involving more than 2,100 women in 17 medical centers have been completed. As of this writing, the data from these studies are being prepared for publication in a medical journal, and a New Drug Application (NDA) has been filed with the Food and Drug Administration. This method is not expected to be generally available until at least 1998.
In some countries this abortion method is used up to the 49th day, in others it is used to the 63rd day. Initially, in the United States, the FDA registration of the drug limited it to use up to the 49th day. Additional information may permit an extension to the 63rd day.
Mifepristone is given in three tablets, taken at the clinic. The woman returns 2 days later for two pills containing a dose of misoprostol. After taking the misoprostol, she must rest in the clinic for a few hours, during which time most women abort. If this does not occur in about 4 hours, she goes home and waits for it to happen sometime during the next 2 weeks. About three-quarters of the abortions take place during the first 24 hours after taking the misoprostol.
Vacuum aspiration may be required in the approximately 5 percent of cases in which the placental tissue is not completely expelled or, occasionally, because of excessive bleeding or because an abortion does not occur at all.
Most of the side effects of this treatment occur right after the misoprostol is taken. The effects of a single dose of misoprostol are cramps, abdominal pain, and bleeding like that of a heavy period. Some patients experience nausea, vomiting, and diarrhea that may be severe enough to require medication. Heavy bleeding may continue for a week; bleeding that is not heavy can last for 1 to 3 weeks. In rare cases of severe bleeding, a woman may require a surgical abortion and/or a blood transfusion. In Europe, 2 to 3 women out of every 1,000 who used this method have needed a transfusion.
In its 10 years of use in Europe, there have been few serious medical problems with this method of medical abortion. Because a small, single dose is used and most of it is eliminated from the body in a few days, the risk of long-term health effects is slim. Almost all healthy women who are not allergic to these drugs can have a medical abortion.
Mifepristone, when it becomes available, will not be sold over the counter or through a prescription. It will be distributed only to qualified physicians who have been trained in using this method and will be given to patients under direct medical supervision. This policy is designed to ensure that the physicians who provide these methods have the information they need to counsel patients, and also have the necessary backup medical services.
Very recently several clinical studies in the United States have shown that another drug combination can induce abortions successfully and safely during early pregnancy. In the studies, a combination of methotrexate and misoprostol was 90 to 95 percent successful when the pregnancy was 49 days or less, but the abortion took longer to complete than with the combination of mifepristone and misoprostol.
Methotrexate prevents cells from dividing and growing. It has been used safely for many years to treat unruptured ectopic pregnancies, some cancers, and some nonmalignant diseases such as psoriasis and rheumatoid arthritis. In the doses used for abortion, it is safe for most healthy women who are not allergic to it.
In this two-step method, after receiving either an injection or tablets of methotrexate, the woman is given a vaginal suppository of misoprostol to be used at home 5 or 6 days later. Many physicians suggest that the woman insert the suppository when she will be able to rest for some time, such as before bedtime or at the start of a weekend, because she can expect about 12 hours of hard cramping and brisk bleeding. Acetaminophen with codeine is prescribed for easing the cramps.
Fifty to 60 percent of women who have used this method had an abortion within 24 hours after inserting the misoprostol. Another 10 to 20 percent abort after using a second suppository. Those for whom the misoprostol is not effective immediately may have to wait 2 to 3 weeks before cramps begin, followed by bleeding.
If the drug regimen is unsuccessful, vacuum aspiration is used to empty the uterus. Only a very small percentage of women require this additional step.
Most women using methotrexate plus misoprostol bleed for 7 to
10 days afterward and have some spotting for an additional 3 to 5 days. About 5 weeks pass before they have a menstrual period, which is similar to the after effects of a surgical abortion.
This method currently is available only at medical centers where it is being studied.
Prostaglandins are chemicals made naturally by the body that act much like hormones. Some have been copied in synthetic versions and have a variety of medical applications. Several stimulate the uterus to contract during labor, for example, and have been used alone as vaginal suppositories or as injections to terminate more advanced pregnancies—those that are between 12 and 24 weeks. Nevertheless, today a prostaglandin alone is rarely used—perhaps in 1 percent of cases. Usually second trimester pregnancies can be ended more easily and with fewer side effects by a D&E. But if a physician is not thoroughly experienced in the D&E technique, pros-taglandin suppositories are a safer alternative because they do not require special surgical expertise. However, a D&C or a D&E still must be done if the prostaglandin fails to work, which happens occasionally. So a physician who does not perform these procedures must be prepared to transfer his patient to a surgeon who does.
If a suppository is used, it is placed high in the vagina, and the hormone is absorbed by the blood supply in the vaginal walls. These prostaglandins stimulate intense, painful contractions of the uterus. Compared to injections, suppositories have the advantage of being removable if a severe adverse reaction develops, before they are totally absorbed.
For advanced pregnancies, the dose of prostaglandin in each tablet needs to be high, and a new tablet usually must be inserted every few hours. The constant high dose frequently produces such side effects as extreme nausea, vomiting, and diarrhea. Such reactions often can be alleviated by medicine prescribed by the physician. About one-half of women who have abortions this way also exhibit a marked rise in temperature. An abortion by prostaglandin sup positories takes an average of 14 hours after the insertion of the first tablet.
A prostaglandin also can be administered as an injection or by an intravenous drip to induce labor contractions. This approach has many side effects and is not always effective. Like the suppository, it causes a high rate of vomiting and diarrhea. Ten to 20 percent of the women who receive prostaglandins alone in any form require a D&C afterward to remove placental tissue that was not expelled.
You need to start using a contraceptive method before you have sex again if you want to be sure you do not get pregnant. Most likely, your surgeon or the clinic counselor will bring up the subject; if they do not, raise the question yourself. If your pregnancy was the result of a contraceptive failure, you may want to change methods.
It is possible to be sterilized when you have an abortion if it takes place before the end of the 10th week of pregnancy, before the uterus becomes large and soft. However, it is only in large urban centers that you may find a clinic able to provide abortion and sterilization services simultaneously. Often, surgeons who perform sterilizations prefer to use general anesthesia, which requires hospi-talization and is more expensive. For information on sterilization and vasectomy, see Chapters 12 and 13, and discuss this option with your physician or the counselor at the clinic.
An early surgical abortion (before 10 weeks), using local anesthesia and performed in a clinic that does many abortions every year, costs an average of $300. Otherwise, costs can range from $140 (for subsidized care) to $1,700 or more, depending on where and when the abortion is done. The price increases sharply for second trimester abortions. Clinics will charge about $600 for an abortion performed at 16 weeks and $1,100 at 20 weeks. These fees can go as high as $2,500 at 16 weeks to $3,000 at 20 weeks, depending on where the procedure is performed. Hospital charges generally are at least several times higher than the fees charged by clinics that specialize in women's reproductive care. In addition, the use of general anesthesia sustantially increases the cost.
A medical abortion in a clinic will cost about the same as an early surgical procedure (about $300), largely because of the extra number of clinic visits that are necessary.
Except in New York, California, and Washington, D.C., Medic-aid generally does not pay for abortions. Some health insurance plans cover the cost of abortions for employees and their dependents. Others pay only for abortions that are necessary for medical reasons. Health maintenance organizations (HMOs), in general, are likely to include abortions in their coverage. Whether your health insurance coverage includes this procedure depends on the individual company writing the insurance or on your particular plan. Many health insurance plans include abortion under maternity benefits.
If you do not know what your health plan coverage includes, get a copy of your benefits sheet from your company's personnel office or from the insurance company. (It may be easier to retain your privacy by talking to the insurance company.) You will need to know your benefits identification number or the name of your health benefits package (such as "Master Medical") when requesting information.
Employees of the U.S. government, including those in the armed services, are not covered for abortion services. Similarly, women who work for state or city governments also may not be covered for abortion by their health insurance.
If you do not have health coverage and cannot afford to pay for an abortion, there may be funds available to you in your community. Women's health groups or feminist groups may make loans or outright grants of money. The hotline of the National Abortion Federation (800-772-9100) has information on sources of financial assistance. In addition, state or local chapters of the National Abortion Rights Action League (NARAL) and the National Organization for Women (NOW) may have a fund earmarked for women who need abortion services. These chapters usually are listed in the white pages of your local telephone directory; if you cannot find them, call their Washington headquarters. (Not all states have chapters of these organizations.) The number of NARAL in Washington is 202973-3000; for NOW it is 202-331-0066. Your local Planned Parenthood affiliate also may have access to private funding sources.
Counselors at abortion clinics also may be knowledgeable about the resources available in their community. Some cities may have little-known, private foundations that help women pay for abortions. If you need financial help, pursue the available resources early and vigorously.
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