What are the abortion options during pregnancy?

Abortion Options During Pregnancy

The most effective and safest abortion options depend on gestational age, with medication abortion using mifepristone plus misoprostol recommended up to 10 weeks, and surgical options preferred beyond that point.

First Trimester Options (Up to 12-13 weeks)

Medication Abortion

• Combination regimen (preferred): Mifepristone 200mg orally followed by misoprostol 800mcg vaginally 24-48 hours later 1
  • Success rate: ~95% complete abortion within 24 hours
  • Available up to 10 weeks (70 days) gestation
  • Advantages: Non-invasive, can be completed at home, more private
  • Contraindications: Severe anemia, coagulopathy, current anticoagulant therapy, known allergy to medications

Surgical Options

• Vacuum aspiration (manual or electric)
  • Success rate: >99%
  • Available up to 13 weeks
  • Advantages: Quick procedure (5-10 minutes), immediate completion, less bleeding than medication abortion
  • Can be performed under local anesthesia with or without sedation

Second Trimester Options (13-24 weeks)

Early Second Trimester (13-16 weeks)

• Dilation and Evacuation (D&E)
  • Safest method for this gestational age 2
  • Involves cervical preparation, dilation, and removal of pregnancy tissue
  • Usually requires more specialized training and equipment

Late Second Trimester (16-24 weeks)

• D&E continues to be commonly used
• Labor induction methods:
  • Mifepristone 200mg followed by misoprostol (most effective regimen) 1
  • When mifepristone unavailable: misoprostol alone (400-800mcg vaginally or sublingually every 3 hours)
  • Success rate with misoprostol alone: 80-85% within 24 hours

Considerations by Gestational Age

Postabortion Care

• First trimester procedural (surgical) abortion: Safe to place IUD immediately 3
• First trimester medication abortion: Safe to place IUD immediately 3
• Second trimester procedural abortion: May require additional considerations for IUD placement 3

Maternal Risk Considerations

• Maternal morbidity and mortality increase with advancing gestational age
• Major complication rates: 0.8% at 11-12 weeks vs. 2.2% at 17-20 weeks 3
• Mortality risk: 1.1 deaths per 100,000 abortions at 11-12 weeks vs. 6.9 deaths per 100,000 at 16-20 weeks 3

Special Circumstances

Previable Premature Rupture of Membranes (PPROM)

• Patients with PPROM at 14-24 weeks should be counseled about both abortion care and expectant management options 3
• Expectant management carries higher risk of maternal morbidity (60.2%) compared to abortion care (33.0%) 3
• Most common complications with expectant management: intraamniotic infection (38.0%) and postpartum hemorrhage (23.1%) 3

Placenta Accreta Spectrum in Previable Period

• Counseling should include discussion of pregnancy termination due to significant maternal morbidity and mortality risks 3
• Requires specialized care by providers experienced in these procedures

Accuracy of Self-Assessment for Medication Abortion Eligibility

• Women can accurately self-assess gestational age for medication abortion eligibility using:
  • Last menstrual period date (83.5% sensitivity)
  • Composite assessment including weeks pregnant, LMP, and conception date (89.1% sensitivity) 4
• This may reduce need for ultrasound in some cases

Important Considerations

• Patient counseling: All options should be presented with accurate information about risks, benefits, and alternatives
• Location of care: Procedures should be performed in facilities with appropriate emergency backup based on gestational age and patient risk factors
• Post-abortion contraception: Should be discussed and provided when desired, with method selection guided by medical eligibility criteria 5
• Follow-up care: Essential to confirm complete abortion and address any complications

Pitfalls to Avoid

• Underestimating gestational age, which can lead to using inappropriate methods
• Failing to recognize contraindications to specific abortion methods
• Not providing adequate pain management during procedures
• Overlooking the need for Rh immunoglobulin in Rh-negative patients
• Delaying abortion care, which increases risks as pregnancy advances

Remember that abortion options and access vary by location due to legal restrictions, and patients should be referred to appropriate resources based on their specific circumstances and needs.