Pocket ObGyn – Pregnancy Termination
See Abbreviations
Early Medical Termination
- Utilizes an established medical regimen to induce an abortion up to 63 d of EGA; A failed medical abortion is defined as the presence of a gestational cardiac activity on transvaginal USG 2 w following medical
- 6% of all abortions in US are medical; <1% of medical terminations <49 d fail, <1% require surgical intervention by D&C for hemorrhage
| Protocols for medical management of pregnancy termination | |||
| Common regimens | EGA | Success | % of continuing Preg |
| Mifepristone 600 mg, misoprostol 400 mg PO 36–48 h later (FDA-approved regimen) | 49 d | 92% | <1% fail, initiated <49 d; 49% aborted w/i 4 h,
75% w/i 24 h |
| Mifepristone 200 mg PO, misoprostol, 800 mg vaginally, simultaneously (alternative evidence-based regimen; preferred regimen) | 63 d | 95–99% | <1% fail if initiated <49 d, continuing Preg 2% if
<63 d |
| Methotrexate, 50 mg/m2 IM or 50 mg vaginally & misoprostol 800 mg vaginally 3–7 d later | 49 d | 92–99% | May require up to 4 w for complete abortion to occur, <1% fail if initiated <49 d |
| Misoprostol, 800 mg vaginally repeated up to 3 dose q3–24h | 63 d | 88% | <1% if initiated <49 d, <72 d, rate of continuing Preg increases 4–10% |
| From Obstet Gynecol 2014;123:676. | |||
| Contraindications to medical abortion | |
| Avoid medical termination in the following pts | |
| Contraindications to mifepristone | Confirmed or suspected ectopic Preg, undiagnosed adnexal mass, IUD in situ, current long-term systemic Cort rx, chronic adrenal failure, sev anemia, known coagulopathy or anticoagulant rx, mifepristone intolerance or allergy |
| Relative contraindications to mifepristone | Sev liver, renal, respiratory dz, uncontrolled HTN, CVD (angina, valvular dz, arrhythmia, or cardiac failure) or sev anemia |
| Contraindications to misoprostol | Uncontrolled sz d/o or those who have an allergy or intolerance to misoprostol |
| Other factors | Pt is able to assume responsibility for care, are anxious for completion of abortion, are able to f/u, no language or comprehension barriers to counseling, IUP w/ GA confirmed, hemodynamically stable. |
| From Obstet Gynecol 2014;123:676. | |
Medical Terminations in the Second Trimester or Termination by Induction
- Upper limit for 2nd trimester surgical termination varies by
- Induction abortion is the termination of Preg by stimulation of labor-like contractions that cause eventual expulsion of the fetus & placenta from the
- US physicians must comply w/ the federal Partial-Birth Abortion ban Act of 2003, which bans abortions wherein the physician deliberately delivers a living fetus vaginally, the point at which any part of the fetal trunk above the navel is outside the woman’s body, & after the fetus reaches the specified point in either presentation breech or vertex, the physician performs an overt & separate maneuver from deliv to kill the
- 10–15% occur in the 2nd trimester; ³13 EGA (12%); 16–20 EGA (3.8%); >21 EGA (1.4%) (MMWR Surveill Summ 2008;57:SS–13)
- Mifepristone & misoprostol (mean 6–11 h for completion). Alternatively, prostaglandin E1 when mifepristone is not available (mean 9–20 h for completion).
Surgical Terminations
- Univ periabortal antibiotic ppx is effective & inexpensive (¯ 42% decreased risk of postabortal infxn): Doxycycline 100 mg PO 1 h preoperatively & a single 200 mg PO dose
- Unsensitized Rh(D) women should receive Rh(D) Ig w/i 72 h 50 mg dose at <13 wga & 300 mg dose <13 wga.
- Contraceptive care initiation w/ long-acting reversible contraceptives may
contraceptive use, improve continuation, reduce rpt Preg & rpt abortion.
- Potential complications may be immediate (intraoperatively or in recovery room) or delayed (w/i few hours postprocedure to 2 w): Retained products of conception, hemorrhage, uterine injury: Cervical tears, uterine perforation, syncope, thromboembolic & cardiorespiratory disorders. Delayed complications also include infxn, persistent intrauterine or ectopic
- D&C: Most commonly performed for 7–13 w By convention D&C = <14 w. Manual vacuum aspiration – use at <10 w EGA, 60 mm Hg suction
Electric vacuum aspiration – for all GAs, 60 mm Hg suction
- D&E: By convention, D&E = >14 w
Mechanically dilate uterine cervix, permitting evacuation of fetal & placental tissue. Most common technique for 2nd trimester terminations (>96%)