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Patient education: Abortion (pregnancy termination) (Beyond the Basics)

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Katherine Simmonds, MS, MPH, WHNP-BC
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Jody Steinauer, MD, MAS
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Sandy J Falk, MD, FACOG
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ABORTION OVERVIEW

Abortion, also known as pregnancy termination, is a procedure that is performed to end a pregnancy. In the United States, abortion is a safe and legal option for women who cannot or choose not to continue with a pregnancy.

Deciding to have an abortion is a very personal decision. Any woman considering abortion should understand the risks and benefits of the various types of abortion, as well as the alternatives to abortion, including parenting and adoption.

This article will help to explain these issues and will briefly discuss legal abortion procedures, including the recommended follow up. If you have questions or concerns about abortion after reading this article, find a supportive healthcare provider or clinic that provides abortion services. (See 'Where to get more information' below.)

IS ABORTION RIGHT FOR ME?

In the United States, 21 percent of pregnancies end in abortion (not including miscarriages) [1]. One in three women will have an abortion by the age of 45 [2].

There are many reasons for considering abortion. Some of the most common reasons include:

Having a baby would interfere with family, work, school, or other responsibilities

Cannot afford to raise a child

Do not want to be a single parent

Having problems with husband or partner

Something is wrong with the fetus

Health problems that make pregnancy a problem

If you are not sure if abortion is the right decision for you, talk to a supportive healthcare provider or find a clinic that provides abortion services. You may also want to talk to a friend, family member, your partner, or someone else you trust. It is important to share your thoughts and feelings about this decision with people who will support you, no matter what you decide. (See 'Where to get more information' below.)

Most states allow abortion until the pregnancy has reached "viability" or 24 weeks. If you are under age 17 or 18 and live in the United States, you may need one or both of your parents' permission to have an abortion. In most states, if it is not possible to get your parents' permission, you can speak with a judge to get permission for an abortion without your parents' or guardian's approval. Healthcare providers who provide abortions can help you with this process if you need it. Laws for each state are available on the websites of some organizations. (See 'Where to get more information' below.)

TYPES OF ABORTION PROCEDURES

There are two basic ways abortions are performed:

One is called "medical" or "medication abortion," meaning that you take medicine to end the pregnancy.

The other is called "aspiration" or "surgical" abortion, meaning that a healthcare provider does a procedure to remove the pregnancy.

Medication or surgical abortion? — The type of abortion procedure you may have depends on a number of factors, including how far along you are in your pregnancy, what type of abortions are available in your area, and your personal preferences. "Early" medication abortion, in which a woman takes medicine by mouth, is most effective if the pregnancy is less than 10 weeks. If the pregnancy is later (beyond 14 to 16 weeks), you may be given medicines that induce labor to cause an abortion. This type of abortion would be performed in a hospital and is usually called "labor induction." It is not as common as aspiration or early medication abortion.

Reasons that you might prefer an early medication abortion:

You prefer to be in the privacy of your home when you pass the pregnancy

You would prefer not to have anesthesia

You would prefer not to have a healthcare provider perform a procedure with medical instruments to remove the pregnancy from your uterus

It is important to know that in approximately 2 percent of cases, the medication may not work and an aspiration procedure is necessary. (See 'How effective is early medication abortion?' below.)

Reasons that you might prefer surgical abortion:

You prefer to have the abortion completed in one visit

You are not comfortable with the idea of heavy vaginal bleeding and passing the pregnancy at home

You would prefer to have anesthesia to minimize pain

Initial evaluation — With both medication and aspiration abortion, you will need the following before the procedure:

A pregnancy test or ultrasound to confirm that you are pregnant and determine how far along the pregnancy is. To determine the current length of your pregnancy, you can use this calculator (calculator 1).

A blood test to determine your blood type and to make sure you do not have anemia. If you have a negative blood type (for example, if you are "A negative"), you will be given an injection of a medication called Rh immune globulin (Rhogam) after the abortion. This helps to prevent complications in future pregnancies.

You may be offered testing for sexually transmitted infections. Commonly performed tests include gonorrhea, chlamydia, and HIV. Testing for syphilis and hepatitis A, B, and C may also be recommended.

You will discuss the risks and benefits of abortion, the available procedures (medication and aspiration), and alternatives to abortion (parenting, adoption) with a counselor or other clinician. This is an important step; if you have any questions or concerns, this is the best time to ask.

In some states, women must wait for a certain amount of time (usually 24 hours) between the counseling, described above, and the abortion. In other states, the abortion can be performed on the same day as the counseling. For information about your state, see http://www.guttmacher.org/statecenter/sfaa.html.

You will discuss options for contraception ("birth control"). After medication or aspiration abortion, you can become pregnant again quickly, even before your next menstrual period. You can start using most methods (pill, patch, vaginal ring, injection, intrauterine device [IUD], implants) on the day of an aspiration abortion.

With medication abortion, you can start some kinds of birth control on the same day you take the medicines. Other methods, like the IUD, can be inserted soon after the pregnancy has ended, usually within a few days after you take the medicine. (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)".)

EARLY MEDICATION ABORTION

Early medication abortion usually involves taking two different medications to end an early pregnancy. In the United States, early medication abortion may be an option if you are less than 10 weeks (70 days) pregnant (clinics have different their policies on this). Medication can also be used for women who are further along in their pregnancy (14 or more weeks), but for this type of abortion, the abortion takes place in the hospital under the supervision of a doctor or nurse. To determine if you can have an early medication abortion, use this calculator (calculator 1).

Early medication abortion is available in some medical offices and hospitals and in most clinics that provide abortion services. The following steps are involved in most cases:

A healthcare provider will confirm how many days pregnant you are, either by using a calculator or an ultrasound of the pregnancy.

You will be given two medications, usually mifepristone and misoprostol. Information about these medications is available online (refer to www.earlyoptionpill.com or www.prochoice.org/about_abortion/facts/medical_abortion.html).

You will take the mifepristone at the clinic or medical office. You will take the misoprostol several hours or days later at home or in another place you choose.

Expected side effects — Abdominal pain, cramps, and vaginal bleeding are expected side effects with early medication abortion. Some women also have fever, nausea, vomiting, or diarrhea.

Pain and cramps — Most women will have abdominal pain and cramps after taking the second medication (misoprostol). These cramps may be mild or strong. The pain usually improves after the pregnancy has passed out of your uterus, which for most women occurs within 2 to 24 hours after taking the misoprostol.

You can take 600 to 800 mg of ibuprofen (Advil, Motrin) every 6 to 8 hours for pain, if needed. Some doctors and nurses also give a prescription for a stronger pain medication to use if needed. You can also use a heating pad on your abdomen. If you have severe pain that is not relieved by these treatments, call your clinic immediately.

Vaginal bleeding — It is normal to experience vaginal bleeding with an early medication abortion. The bleeding may be heavy, especially in the first few hours after you take the misoprostol. The bleeding usually decreases after you pass the pregnancy tissue out of your uterus, and then continues for several weeks. It should be lighter than a menstrual period after the first few days.

If you are bleeding so heavily that you soak through one menstrual pad per hour for two hours in a row and you are still bleeding, you should call your healthcare provider or clinic immediately. If you do not have bleeding at all after you take the medications, you should also call your doctor or nurse.

Fever, nausea, vomiting, diarrhea — Some women experience a mild fever, nausea, vomiting, or diarrhea after taking the second medication (misoprostol). This usually goes away quickly on its own without treatment. If you develop a fever higher than 100.4ºF (38ºC), or if you have chills, vomiting, or diarrhea that does not go away within several hours, call your doctor or nurse.

How effective is early medication abortion? — Early medication abortion is very effective in ending pregnancies up to 70 days (10 weeks).

If early medication abortion does not work in ending your pregnancy, you will need to have an aspiration abortion to remove it. Continuing a pregnancy after taking medications for an abortion is not safe due to the risk of birth defects from the misoprostol. For signs that your abortion was not effective, (see 'When to seek help after abortion' below).

ASPIRATION OR "SURGICAL" ABORTION

Aspiration abortion is a procedure that is done in a clinic or hospital to end a pregnancy. The procedure is done by removing the pregnancy tissue from the uterus through the opening, called the cervix. (See "Surgical termination of pregnancy: First trimester".)

In most cases, you can choose to have an aspiration abortion while you are awake, using only local anesthesia, or while you are sedated. Some providers also offer other medicines to reduce pain and anxiety, including medicines you can take by mouth. If you are more than 14 weeks pregnant, you will probably need to have sedation. To determine how far along your pregnancy is, use this calculator (calculator 1). (See "Overview of second-trimester pregnancy termination".)

A healthcare provider gives local anesthesia by injecting medication into your cervix (the opening to your uterus). This usually causes some mild pain that passes quickly. You will not require an intravenous (IV) line if you have only local anesthesia.

If you do decide to have sedation, you will have an IV line placed in a vein, and medication will be given to make you relax or feel sleepy. Many people do not remember much about the procedure after the sedative medication is given. You will also be given local anesthesia, after the sedative. General anesthesia (that makes you completely unconscious) is not recommended for abortion in most cases.

The abortion procedure usually takes between 5 and 20 minutes, and is usually shortest when the pregnancy is early. You will be monitored in a recovery area for about an hour after the procedure (longer if you are given a sedative).

Expected side effects — Vaginal bleeding, abdominal pain, and cramping are expected side effects after an aspiration abortion.

Abdominal pain and cramping — Most women have some abdominal pain and cramping after an aspiration abortion. You can take 600 to 800 mg ibuprofen (Advil, Motrin) every 6 to 8 hours for pain, if needed. Some doctors give a prescription for a stronger pain medication that you can take if needed.

The pain usually lasts several hours. If you have severe pain that does not get better with these treatments or if your pain continues for more than a few days after the procedure, call the clinic where you had the abortion, or your doctor or nurse.

Vaginal bleeding — It is normal to have some vaginal bleeding after an aspiration abortion. Usually the bleeding is less than with a menstrual period. The bleeding usually lasts a few days to two weeks, and should become light after the first few days. You may also pass some tissue or blood clots.

If you are bleeding so heavily that you soak through a menstrual pad in an hour for two or more hours in a row and you are still bleeding, you should call the clinic where you had the abortion or your healthcare provider.

WHEN TO SEEK HELP AFTER ABORTION

Call the clinic where you had the abortion or your healthcare provider immediately if:

You are bleeding so heavily that you soak through one menstrual pad per hour for two hours in a row and you are still bleeding.

You have severe pain that is not relieved by pain medications.

You have shaking chills or develop a temperature higher than 100.4ºF or 38ºC (use a thermometer to measure your temperature).

You have foul-smelling or pus-like vaginal discharge.

In addition, you should be aware of signs that your abortion was not complete. Call your healthcare provider if:

You do not have vaginal bleeding after a medication abortion.

Your pregnancy symptoms (breast tenderness, nausea) do not resolve within one week after your abortion. You should not do a home pregnancy test, even if you still feel pregnant, because it is likely to be positive for up to 6 weeks after having an abortion.

You continue to bleed for more than 2 weeks after your abortion.

You do not have a menstrual period within 6 weeks after your abortion.

FOLLOW-UP CARE

Different clinicians and clinics make different recommendations, but in general, you should avoid sex or putting anything in your vagina (tampons, douches) for at least a few days to a week after an abortion. This may help prevent infection and give you time to recover.

About one week after a medication abortion, you should have a follow-up visit with the healthcare provider or clinic where you were given the medication. It is very important to go to this visit to be sure you are no longer pregnant.

Approximately two weeks after an aspiration abortion, many abortion providers recommend that you have a follow-up visit with your primary care provider or a provider at the site where you had the abortion. At this visit, you can review how you are feeling and discuss contraception ("birth control"). If you have not already started using a contraceptive method, you should discuss what will be best for you at this follow-up visit (see "Patient education: Birth control; which method is right for me? (Beyond the Basics)"). The provider may also need to perform a pelvic exam.

ABORTION COMPLICATIONS

Legal abortions are safe and usually cause no serious complications. However, complications do sometimes occur, as with any medical or surgical procedure. Complications can include excessive bleeding, infection, injury to the cervix or uterus (aspiration procedures only) and the potential need to remove pregnancy tissue by aspirating the uterus. These complications occur in a very small number of cases [3,4].

MYTHS AND FACTS ABOUT ABORTION

Abortion is not safe – MYTH. Legal abortions are one of the safest medical procedures available today. While abortion is not risk-free, the risk of having an abortion is far less than the risk of carrying a pregnancy and giving birth. Abortions done early in pregnancy (before 13 weeks of pregnancy) have fewer risks than abortions done later in pregnancy [3,5].

Abortions that are performed by someone without training are not safe and can lead to serious complications, including bleeding, infection, infertility, and even death – FACT.

Abortion will make me infertile – MYTH. Legal abortions do not make it more difficult to become pregnant in the future [6].

Abortion increases my risk of breast cancer – MYTH. Several studies have conclusively shown that having an abortion does NOT increase the risk of developing breast cancer [7,8].

Abortion increases my chance of miscarriage – PROBABLE MYTH. There have been a number of studies that have tried to determine if abortion increases the risk of miscarriage with future pregnancies. Most well-designed studies have not found that legal abortion in the first trimester increases the risk of miscarriage, preterm delivery, or other pregnancy complications [9-11].

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Abortion (The Basics)
Patient education: Pregnancy in Rh-negative women (The Basics)
Patient education: Spina bifida (myelomeningocele) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Birth control; which method is right for me? (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Induced fetal demise
First-trimester medication abortion (termination of pregnancy)
Misoprostol as a single agent for medical termination of pregnancy
Overview of pregnancy termination
Postpartum contraception
Surgical termination of pregnancy: First trimester
Overview of second-trimester pregnancy termination

The following organizations also provide reliable health information.

National Library of Medicine

(www.nlm.nih.gov/medlineplus/abortion.html)

Guttmacher Institute

(www.guttmacher.org)

Planned Parenthood

(www.plannedparenthood.org)

National Abortion Federation

(www.prochoice.org)

Reproductive Health Technologies Project

(www.rhtp.org)

Literature review current through: Nov 2016. | This topic last updated: Thu May 19 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
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  1. Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011. Perspect Sex Reprod Health 2014; 46:3.
  2. Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstet Gynecol 2011; 117:1358.
  3. Lichtenberg ES, Grimes DA. Surgical Complications: Prevention and Management. In: Management of Unintended and Abnormal Pregnancy, Paul M, Lichtenberg ES, Borgatta L, et al. (Eds), Blackwell Publishers, 2009.
  4. Medical management of first-trimester abortion. Contraception 2014; 89:148.
  5. Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol 2012; 119:215.
  6. Boonstra H, Gold R, Richards C, Finer L. Abortion in women’s lives. Guttmacher Institute, New York 2006.
  7. Beral V, Bull D, Doll R, et al. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83?000 women with breast cancer from 16 countries. Lancet 2004; 363:1007.
  8. Committee on Gynecologic Practice. ACOG Committee Opinion No. 434: induced abortion and breast cancer risk. Obstet Gynecol 2009; 113:1417.
  9. Atrash HK, Hogue CJ. The effect of pregnancy termination on future reproduction. Baillieres Clin Obstet Gynaecol 1990; 4:391.
  10. Zhou W, Nielsen GL, Larsen H, Olsen J. Induced abortion and placenta complications in the subsequent pregnancy. Acta Obstet Gynecol Scand 2001; 80:1115.
  11. Kalish RB, Chasen ST, Rosenzweig LB, et al. Impact of midtrimester dilation and evacuation on subsequent pregnancy outcome. Am J Obstet Gynecol 2002; 187:882.

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.