What are the options for pregnancy termination?

Options for Pregnancy Termination

For first-trimester termination (up to 7-9 weeks), mifepristone 200 mg followed by misoprostol 800 μg is the medical option, while vacuum aspiration is the surgical option; for second-trimester termination, dilation and evacuation (D&E) is the safest and preferred method with significantly lower complication rates than medical alternatives. 1, 2, 3

First Trimester Termination (Up to 9-13 Weeks)

Medical Method

• Mifepristone 200 mg orally followed by misoprostol 800 μg (oral or vaginal) 24-48 hours later is the recommended medical regimen 1, 3
• Efficacy is gestational age-dependent: 92% success at ≤49 days, 83% at 50-56 days, and 77% at 57-63 days 4
• Mifepristone up to 7 weeks gestation can be used as an alternative to surgical evacuation 1, 2
• If mifepristone is unavailable, misoprostol alone can be used, though repeated doses may be required and complete abortion rates may be lower 3
• Complete abortion rates with medical methods are approximately 95% 3

Surgical Method

• Vacuum aspiration (either electrical suction or manual aspiration) is the surgical method of choice 3
• Complete abortion rates with surgical methods are approximately 97% 3
• Risk of significant bleeding is ≤5%, while major complications occur in <1% 3
• Prophylactic antibiotics significantly reduce infection risk (1.3% with antibiotics vs 5-20% without) 1, 2, 3

Second Trimester Termination (14-27 Weeks)

Surgical Method (Preferred)

• Dilation and evacuation (D&E) is the safest procedure for second-trimester termination and should be the preferred method 1, 2, 5
• D&E has dramatically lower complication rates compared to medical methods: hemorrhage risk 9.1% vs 28.3%, infection risk 1.3% vs 23.9% 2, 5
• Most D&E procedures are performed under sedation or general anesthesia 2, 5
• Should be performed in a hospital setting by experienced providers with emergency support services available 1, 2

Medical Method (Alternative)

• Prostaglandin E1 (misoprostol) or E2 can be administered if surgical evacuation is not feasible 1, 5
• These agents lower systemic vascular resistance and blood pressure while increasing heart rate, with E2 having greater effects than E1 1
• Systemic arterial oxygen saturation must be monitored with transcutaneous pulse oximetry during prostaglandin administration 1, 5
• Prostaglandin F compounds should be avoided as they significantly increase pulmonary arterial pressure and may decrease coronary perfusion 1, 5
• Saline abortion should be avoided due to risks of volume expansion, heart failure, and clotting abnormalities 1

Critical Procedural Considerations

Timing and Setting

• First trimester is the safest time for elective pregnancy termination 1
• All terminations should be performed in a hospital rather than outpatient facility to ensure emergency support services are available 1, 2
• High-risk patients (those with cardiac disease, pulmonary hypertension, cyanosis) should be managed in experienced centers with on-site cardiac surgery 1, 5

Post-Procedure Care

• Antibiotic prophylaxis is recommended to prevent post-abortal endometritis, which occurs in 5-20% of women not given antibiotics 1, 2, 5
• Rh-negative women must receive anti-D immunoglobulin to prevent alloimmunization 2, 5, 6
• Monitor for signs of infection, retained products, and excessive bleeding 2

Anesthesia and Pain Management

• Anesthesia and pain management should be provided based on the method chosen 2
• Fetal analgesia is not recommended during pregnancy termination procedures as there is no evidence of fetal pain awareness before 24-25 weeks gestation 2, 5

Special High-Risk Situations

Cardiac Disease and Pulmonary Hypertension

• Women with congenital heart disease and pulmonary arterial hypertension (CHD-PAH) who become pregnant should undergo the earliest possible pregnancy termination after counseling 1
• Pregnancy termination in the last 2 trimesters poses high maternal risk in these patients, though may be reasonable after balancing risks 1
• Termination in the first trimester is the safer option for these high-risk patients 1

Common Pitfalls to Avoid

• Do not use prostaglandin F compounds due to adverse hemodynamic effects 1, 5
• Do not perform saline abortion due to volume and clotting risks 1
• Do not delay termination beyond first trimester in high-risk cardiac patients 1
• Do not perform procedures in outpatient settings for patients with significant medical comorbidities 1