COMMENTARY

The Safest Methods for Inducing Abortion

Peter Kovacs, MD, PhD

Disclosures

August 30, 2017

Induced Abortion

ESHRE Capri Workshop Group
Hum Reprod. 2017;32:1160-1169

Background

Pregnancy-related complications are the sixth leading cause of death in women between the ages of 20 and 34 in the United States.[1] It is estimated that half of the pregnancies are not planned, and of these, almost half are terminated.[2]

In most countries, abortion laws regulate the procedures. These regulations vary from very restrictive to more liberal. In countries with strict abortion laws, the rate of unsafe abortions is higher. They are associated with significant morbidity and mortality.[3]

Summary

In the current paper, the authors note the estimated rate of abortions globally to be 35/1000 women between 2010 and 2014, down from 40/1000 from 1990-1994.

The recommended surgical option, according to the authors, is vacuum aspiration in the first trimester. In the second trimester, dilatation and evacuation should be offered. Cervical dilatation is typically achieved with osmotic dilators.

Up until 9 weeks gestation, 200 mg mifepristone followed by 800 µg of misoprostol is the recommended regimen for medical abortion. A second-trimester abortion can be attempted with 200 mg mifepristone followed by repetitive doses of misoprostol.

The most common complications of induced abortions are continuing pregnancy, retained products of conception, infection, and surgical trauma to the uterus. Retained products of conception can be managed surgically (vacuum aspiration is preferred) or with the use of misoprostol. Antibiotic prophylaxis using doxycycline or azithromycin reduces infectious complications with surgical abortion.

Induced abortion is not associated with subsequent extrauterine pregnancy, infertility, pregnancy loss, or abnormal placentation. It is, however, associated with subsequent preterm birth. Some reports suggest an association between induced abortion and breast cancer, but this has not been confirmed by others.

Anti-D vaccine should be given to nonsensitized Rh-negative women. Routine follow-up is not needed when products of conception have been visualized after the intervention. It is important to offer effective contraception as well as counseling regarding safe sexual practices post-abortion.

Viewpoint

Even the most highly effective contraceptive methods may fail, leading to an unplanned pregnancy. As discussed in this paper, restrictive laws will not prevent induced abortions but will drive patients to unsafe procedures. Unsafe abortions are associated with a higher rate of postprocedure infections, more bleeding complications, and surgical trauma. This contributes to morbidity and mortality among reproductive-age women.

Until a 100% effective contraception becomes available, abortion will exist. It is the healthcare provider's job to educate women about the risks and benefits of continuing pregnancy versus induced abortion. If the patient elects to terminate the pregnancy, then safe medical or surgical procedures are available that are associated with significantly less morbidity and mortality when compared with unsafe or illegal procedures or with continuing pregnancy.

Abstract

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