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Doneen Hollingsworth, Secretary of Health
South Dakota Department of Health

Induced Abortion Methods & Risks

Descriptions of abortion methods commonly used for each trimester of pregnancy are provided below. A list of references for the information is also included. The methods are listed in alphabetical order. Any of the below mentioned risks or complications can be lessened with good medical care.

Contents

First Trimester Abortion Methods (0-14 weeks of pregnancy)
Second Trimester Abortion Methods (14-26 weeks of pregnancy)
Third Trimester Abortion Methods (26-40 weeks of pregnancy)
Glossary
Explanations of Risks
Expectations after Surgery
Fetal Pain
Sources

First Trimester Abortion Methods (0 - 14 weeks of pregnancy)

Dilation and Sharp Curettage (D & C)
In this type of procedure, the cervix is slowly opened and the fetus, placenta and membranes are scraped from inside the uterus with a sharp instrument.

Possible Complications

  • Incomplete abortion requiring vacuum aspiration
  • Infection of the uterus
  • Excessive bleeding
  • Torn cervix
  • Infection of fallopian tubes
  • Punctured uterus
  • Blood clots in the uterus
  • Reaction to anesthesia

Methotrexate/Misoprostol (Methotrexate/Misoprostol information from WebMD)

This is a type of medical abortion with the first medication, Methotrexate, being given by injection into the muscle, followed by vaginal placement of misoprostol.

The fetus, placenta and membranes are generally expelled the next day. If not, the dosage of misoprostol is repeated.

Possible Complications

  • Incomplete abortion which may necessitate a surgical abortion
  • Allergic reaction to medications
  • Prolonged bleeding
  • Nausea and vomiting
  • Diarrhea
  • Abdominal pain and cramping

Mifepristone/Misoprostol (RU-486) (Mifeprex [mifepristone] Information from the FDA)

This medication can be taken up to 5 weeks after conception or approximately 7 weeks after the first day of your last normal menstrual period.

The woman is given Mifepristone to be taken by mouth. After a period of time in the doctor's office, she may return home. At 36 - 48 hours after this dose, the woman returns to receive the proper amount of misoprostol.

The client should then be watched closely by doctors and nurses for a few hours. The fetus, placenta and membranes are usually expelled during this time. (For further information from the FDA see www.fda.gov)

The woman should return to the doctor's office on 14th day after taking the medication to assure that there are no problems and that the fetus, placenta and membranes have been fully expelled.

Possible Complications

  • Incomplete abortion which may necessitate a surgical abortion
  • Allergic reaction to medications
  • Prolonged bleeding
  • Nausea and vomiting
  • Diarrhea
  • Abdominal pain and cramping

Vacuum Aspiration

This is the most common abortion procedure in the first trimester, with 97% of all abortions during that time period being performed in this manner.

The cervix is opened enough to allow the insertion of a suction catheter (tube).

The fetus, placenta and membranes are then removed by the use of the specially designed suction catheter or vacuum device.

This method generally takes approximately 5 minutes after the cervix has been opened.  The procedure used for cervical dilatation can take several hours.

Possible Complications

  • Incomplete abortion which may necessitate a surgical abortion
  • Infection of the uterus
  • Excessive bleeding
  • Torn cervix
  • Infection of fallopian tubes
  • Punctured uterus
  • Blood clots in the uterus
  • Reaction to anesthesia
  • Infertility

Second Trimester Abortion Methods (14 - 26 weeks of pregnancy)

Abdominal Hysterotomy

Similar to a caesarean birth, an incision is made in the uterus and the fetus is removed.
It is usually performed in cases of failed prostaglandin or intra-amniotic instillations.
Anesthesia is given to the woman so she will not feel the surgery.

Possible Complications

  • Infection of incision
  • Severe systemic infection (sepsis)
  • Blood clots to the heart, lungs and brain (emboli)
  • Stomach contents breathed into the lungs (aspiration pneumonia)
  • Injury to the urinary tract
  • Blood clots in the uterus
  • Heavy bleeding
  • Pelvic infection
  • Retention of pieces of the placenta
  • Reaction to the anesthesia
  • Infertility

Dilation and Evacuation

This procedure is performed under local anesthetic between 13 and 20 weeks of pregnancy.

It involves the gradual opening of the cervix and removal of the fetus, placenta and membranes by alternating suction and sharp curettage.

This is currently the most common method used in the second trimester.

Possible Complications

  • Blood clots in the uterus
  • Heavy bleeding
  • Cut or torn cervix
  • Perforation (puncture) of the wall of the uterus
  • Pelvic infection
  • Incomplete abortion
  • Reaction to the anesthesia
  • Infertility

Intra-Amniotic Instillations

Solutions of hypertonic urea and a prostaglandin may be instilled into the amniotic sac after partial removal of the amniotic fluid.

Urea kills the fetus, and prostaglandin helps ensure expulsion.

Contractions begin within 8 to 12 hours and may last 48 hours before the fetus, placenta and membranes are expelled.

Possible Complications

  • Retention of pieces of the placenta
  • Pelvic infection
  • Heavy bleeding
  • Ruptured uterus
  • Blood clots
  • Incomplete abortion
  • Reaction to anesthesia
  • Infertility

Vaginal Prostaglandin

Prostaglandin E2 causes the uterus to contract and the cervix to soften and open.

These actions result in the eventual expulsion of the fetus, placenta and membranes.

The prostaglandin is supplied in the form of vaginal suppositories or gels applied to the cervical canal.

Oxytocin may be given after the administration of the prostaglandin if labor contractions are not strong enough.

Possible Complications

  • Retention of pieces of the placenta
  • Pelvic infection
  • Heavy bleeding
  • Ruptured uterus
  • Blood clots
  • Incomplete abortion
  • Reaction to anesthesia

Third Trimester Abortion Methods (26 - 40 weeks of pregnancy)

Abdominal Hysterotomy

See above

Intact Dilation and Extraction (Partial Birth Abortion)

In this procedure, the physician pulls the fetus feet-first out of the uterus into the birth canal, except for the head which is kept lodged just inside the uterus.

The base of the fetus's skull is punctured with a sharp instrument such as a long scissors or pointed metal tube.

A catheter is inserted into the wound and removes the fetus's brain with a powerful suction machine.  This causes the skull to collapse, and allows for the expulsion of the fetus.

Possible Complications

  • Risks are similar to childbirth
  • Uterine infection
  • Blood clots to heart, lungs and brain
  • Heavy bleeding
  • High blood pressure
  • Reaction to anesthesia
  • Infertility

Glossary

Amniotic sac: Membrane bag that contains the fetus and fluid before birth.

Cervix: Lowest and narrow end of the uterus; the neck, which extends into the vagina.

Conception: Union of the sperm and egg resulting in fertilization.

Curettage: Scraping of the lining of the uterus with a sharp instrument to remove fetus, placenta and membranes.

Dilatation: Stretching of the mouth of the uterus (cervix) to open wide enough to allow passage of the baby.

Fetus: SDCL 34-23A-1 (2) and SDCL 34-25-1.1 (4) define fetus as "the biological offspring, including the implanted embryo or unborn child, of human parents."

Hypertonic Urea: A solution containing a large amount of salts.

Incision: Surgical cut.

Intra-Amniotic Instillation: Putting liquids that contain large amounts of salts into the amniotic sac.

Local Anesthetic: The use of medication to numb a small area of the body.

Membranes: Thin layer of tissue that surrounds the fetus.

Oxytocin: Drugs that cause the uterus to contract.

Placenta: Flattened, round mass of spongy tissue that contains a lot of blood vessels. It attaches to the inside of the wall of the uterus and carries food and oxygen to the fetus, and carries wastes away from the fetus.

Prostaglandin: Substance present in many body tissues. Used to induce abortions or labor.

Suction Catheter: A tube that sucks the fetus, placenta and membranes from the uterus.

Suppositories: A cone-shaped semi-solid substance used to put medication in the vagina.

Systemic: Pertains to the whole body. Involves many organ systems.

Trimester: One of three periods of about 3 months each into which pregnancy is divided.

Vacuum Device: A machine that uses suction to remove the fetus, placenta and membranes.

Explanation of Risks

Any of the below mentioned risks may be lessened with good medical care.

Anesthesia is generally given for surgical abortions (D & C, Vacuum Aspiration, Dilation and Evacuation, Abdominal Hysterotomy, Intra-amniotic instillations, and Intact Dilation and Extraction)

Reactions to anesthesia:
  • Reactions to medications
    • An adverse drug reaction is any effect not intended by proper use of a medication.
    • Reactions also can occur between medications, even non-prescription ones.
  • Problems breathing

    Shortness of breath has many different causes.

    • Blockage of the air passages of the nose, mouth, or throat may lead to difficulty breathing.
    • Heart disease can cause shortness of breath if the heart is not able to pump enough blood to supply oxygen to the body.
    • If the brain, muscles, or other body organs do not receive enough oxygen, a sense of breathlessness may occur.
    • Sometimes emotional distress, such as feeling anxious can lead to difficulty breathing.
Risks for any surgery are:
  • Bleeding
    • This condition involves losing blood.
    • This can occur internally (when blood leaks from blood vessels inside the body), externally through a natural opening (vagina, mouth or rectum) or externally through a break or wound in the skin.
  • Infection
    • A disease caused by microorganisms (germs), especially those that release toxins or invade body tissues.
Additional risks of abortion include:
  • Excessive bleeding
    • Excessive bleeding or hemorrhage is defined as the rapid loss of blood of more than 1% of body weight or 10% of total blood volume.
    • Rapid loss of more than 1.5 to 2 liters of blood may result in hypovolemic (low blood volume) shock.
    • Early symptoms would include pale, clammy skin, decreased urine output, discoloration (turning blue) of lips and nail beds.
    • These may be followed closely by feelings of anxiety, restlessness and shortness of breath.
  • Infection of the uterus
    • Infections of the uterus can be decreased by screening and treating for sexually transmitted diseases before the abortion, by complete emptying of the uterus and by giving antibiotics as a preventative measure when surgical methods have been used.
    • Symptoms of infection may include abdominal pain, and or backache, cramping, fever and or chills, foul vaginal discharge, and pelvic discomfort.
  • Intrauterine blood clots
    • These can occur either right away or as long as 5 days after a surgical abortion.
    • Symptoms include severe cramping and pain without bleeding.
  • Infection of fallopian tubes (which can cause scarring and lead to infertility)
    • Pelvic inflammatory disease (PID) is one of the major causes of infertility (a woman has difficulty or is unable to conceive a pregnancy), ectopic pregnancy (pregnancy outside of the uterus), and chronic pelvic pain.
    • PID can result from microorganisms (germs) transmitted during an abortion.
    • Symptoms include lower abdominal pain, fever and chills, nausea and vomiting, unusual vaginal bleeding or foul smelling discharge.
  • Puncture (perforation) of the uterus, or damage to the cervix (rare)
    • Puncture of the uterus and tearing of the cervix are complications of surgical abortion.
    • Depending on their severity, these complications may require attention ranging from simple observation to hysterectomy (removal of the uterus).
  • Prolonged bleeding
    • Bleeding following a medical abortion may last for 30 days or more.
    • Rarely, excessive bleeding may require a D & C (scraping of the lining of the uterus) or blood transfusion.
  • Incomplete abortion necessitating a surgical abortion
    • Some parts of the fetus, placenta or membranes may be retained resulting in the need for a follow-up curettage.
  • Nausea or Vomiting
    • According to FDA trials, nausea occurred in 61% of women after taking Mifepristone and Misoprostol, whereas vomiting occurred in 26%.
  • Diarrhea
    • According to FDA trials, diarrhea occurred in 20% of women after taking Mifepristone and Misoprostol.
  • Abdominal pain and cramping
    • According to FDA trials, abdominal pain and cramping occurred in 96% of women after taking Mifepristone and Misoprostol.
  • Infertility
    • Difficulty or inability to conceive.
    • Generally results from damage to the fallopian tubes, uterus or cervix either directly by surgical procedure or as the result of infection.
  • Blood Clots to the heart, lungs or brain
    • With any surgical procedure, blood clots may form or break loose, and travel to the heart, lungs or brain. Heart attack, pulmonary emboli, or stroke may result.

Expectations after Surgery

Most women who undergo surgical abortions done in appropriate medical facilities recover without physical complications.

Any significant emotional and psychological issues should be considered and addressed before and after a chosen abortion.

Fetal Pain

Findings from some studies suggest that the unborn fetus may feel physical pain.

Sources

Maternity Nursing, Fifth Edition
Deitra Leonard Lowdermilk, RNC, PhD, FAAN; Shannon E. Perry, RN, PhD, FAAN; Irene M. Bobak, RN, PhD, FAAN
Lowdermilk, Perry and Bobak
Mosby, Inc. 1999

Ingalls and Salerno's Maternal and Child Health Nursing, Ninth Edition
Julie C. Novak, DNSc, RN, CPNP; Betty L. Broom, PhD, RN
Mosby, Inc. 1999

Maternal-Infant Nursing Care, Third Edition
Elizabeth Jean Dickason, RN, MA, Med; Bonnie Lang Silverman, RNC, MS, NNP; Judith A. Kaplan, RN, ACCE, PhD
Mosby, Inc. 1999

"Dilation and Extraction for Late Second Trimester Abortions" in "Second Trimester Abortion: From Every Angle"; Fall Risk Management Seminar, Sept. 13 - 14, 1992 Dallas, TX; Martin Haskell, MD

Taber's Cyclopedic Medical Dictionary, Edition 19
F. A. Davis Company
Philadelphia, PA
Published 2001

Medline Plus Health Information
A service of the U.S. National Library and the National Institute of Health
www.nlm.nih.gov

Contraceptive Technology, Seventeenth Revised Edition
Robert A. Hatcher, James Trussell, Felicia Stewart, Willard Cates Jr., Gary K. Stewart, Felicia Guest, Deborah Kowal
Published by Ardent Media, Inc. 1998

Merck Manual of Diagnosis and Therapy, Section 18. Gynecology and Obstetrics, Seventeenth Edition
Editors: Mark H. Beers, M.D. and Robert Berkow, M.D.
Published by Merck and Co., Inc. Copyright 1999-2003

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