The latest article in our Clinical Practice series is, “A Request for Abortion.” In early pregnancy, medical abortion avoids a surgical procedure but is associated with more pain and bleeding and a slightly higher risk of incomplete abortion than is surgical abortion. Data show that neither type of abortion increases the risk of long-term mental health problems or breast cancer or adversely affects fertility.
Induced abortion is one of the most common medical interventions. About one in three women will have had an induced abortion by the time she reaches menopause.
• What assessment should take place prior to induced abortion?
Once the woman’s choice to proceed with an abortion has been clearly established and written informed consent has been obtained, there is no need for further delay, which may only increase the risk of complications. Counseling should be offered only if the woman requests it or there is a perceived need for it. The blood-group rhesus type should be determined and Rh immune globulin should be administered in Rh-negative women. Cytologic screening of the cervix and screening for sexually transmitted diseases should be offered as appropriate.
• What is the current regimen for medical abortion in the United States?
Medical abortion involves the combined use of the progesterone antagonist RU-486 (now known as mifepristone), which initiates the abortion, and a prostaglandin, which causes uterine contractions and empties the uterus. Today, the most commonly used prostaglandin is the prostaglandin analogue misoprostol; its advantages include stability (which facilitates short-term storage), possible administration by several routes (vaginal, buccal, sublingual, and oral), and low cost. Most clinics wait 24 to 48 hours after mifepristone administration to administer misoprostol. Once medications have been administered, abortion can be completed at home.
Morning Report Questions
Q: Does the frequency of complications differ in medical as compared to surgical abortion?
A: Medical abortion results in more pain, more prolonged bleeding (up to 2 weeks after administration of misoprostol), and a slightly higher failure rate than surgical abortion. Surgical abortions are associated with higher rates of rare complications requiring major surgery than medical abortion. Some women prefer surgical methods that are simple, quick, and associated with a low risk of complications or failure. Others may favor medical methods because they do not involve surgical instrumentation and may appear to be more natural (i.e., more like a miscarriage).
Q: What are the long-term sequelae associated with induced abortion?
A: Few long-term sequelae are evident after abortion, and the morbidity and mortality are lower with induced abortion (either medical or surgical) than with pregnancy carried to term. Induced abortion is not associated with an increased subsequent risk of ectopic pregnancy, placenta previa, infertility, or miscarriage. An association between induced abortion and a subsequent risk of preterm birth, which increases with the number of abortions, has been reported; however, data from prospective cohort studies have not confirmed this finding. There are no data to suggest that medical abortion differs from surgical abortion with respect to these risks.