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, almost 50 percent of pregnancies are unintended, and almost half of these end through abortion [1].

Women have many reasons for considering abortion. Some of the most common reasons include the following:

• Having a baby would interfere with family, work, school, or other responsibilities
• Unable to afford raising a child
• Do not want to be a single parent
• Having problems with husband or partner
• Find out that something is wrong with the fetus
• Have 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 a clinic that provides abortion services. You may also want to talk to a friend, family member, or your partner. It is important to share your thoughts and feelings about this decision with people who you can trust and 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 needed. The 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 "surgical" or “aspiration” abortion, meaning that a health care provider does a procedure to remove the pregnancy.

Medication or surgical abortion? — The type of abortion procedure you 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 she is less than 8 to 9 weeks pregnant. If your 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 surgical or “early medication” abortion.

Reasons that you might prefer an early medication abortion:

• You would prefer to be in the privacy of your home when you pass the pregnancy tissue
• You would prefer to avoid having anesthesia
• You would prefer to avoid medical instruments being inserted into your uterus to remove the pregnancy. In 2 percent of cases, medication abortion does not end or completely remove the pregnancy tissue from inside the uterus and a surgical procedure is needed. (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 pregnancy tissue at home
• You would prefer to have anesthesia to minimize pain

Initial evaluation — With both medication and surgical 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 your pregnancy is. To determine the current length of your pregnancy, you can use this calculator (calculator 1).
• A blood test to determine your blood count (to make sure you do not have anemia) and blood type. If you have a negative blood type (eg, 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 surgical), and alternatives to abortion (parenting, adoption) with a counselor, doctor, or nurse. This is an important step; if you have any questions or concerns, this is the 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 www.guttmacher.org/statecenter/spibs/spib_MWPA.pdf
• You will discuss options for birth control. After medication or surgical 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 birth control after your pregnancy has ended, usually within a few days after your first visit. (See "Patient information: 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 7 to 9 weeks or less (49 to 63 days) pregnant (clinics vary in their policies on this). Medication can also be used for women who are 14 or more weeks, but for this type of abortion, the woman is 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 by using ultrasound measurements of the pregnancy.
• You will be given two medications, usually mifepristone and misoprostol. Information about these medications is available online (see 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, usually at home.

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, within 4 to 6 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 that are up to 49 days (less than 7 weeks). It is nearly as effective in ending pregnancies up to 56 or 63 days (8 or 9 weeks).

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

SURGICAL ABORTION

Surgical 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 a surgical 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 take by mouth. If you are more than 14 weeks pregnant, you will probably require sedation. To determine how far along your pregnancy is, use this calculator (calculator 1). (See "Termination of pregnancy: Second trimester".)

A health care provider gives local anesthesia by injecting your cervix with anesthetic medication. 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 have sedation, you will have an IV line placed in a vein, and medication will be given to make you 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 (where you are completely unconscious) is not recommended for abortion in most cases.

The procedure usually takes between 5 and 20 minutes, and is usually shortest in early pregnancy. 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 a surgical abortion.

Abdominal pain and cramping — Most women have some abdominal pain and cramping after a surgical 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 your doctor or nurse.

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

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.

WHEN TO SEEK HELP AFTER ABORTION

Call your doctor or clinic 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

You should not have sex or put anything in your vagina (tampons, douches) for two weeks after an abortion. Putting anything in the vagina before this time could lead to an infection.

About one week after a medication abortion, you should have a follow up visit with your doctor or nurse. It is very important to go to this visit to be sure you are no longer pregnant.

Approximately two weeks after a surgical abortion, you should have a follow up visit with your primary care provider or a provider at the site where you had the abortion. At this visit, your will have a pelvic examination and can review how you are feeling.

If you have not already started using birth control, you should discuss what method is best at this follow up visit. (See "Patient information: Birth control; which method is right for me? (Beyond the Basics)".)

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, injury to the cervix or uterus, infection, and the potential need for more surgery to remove pregnancy tissue. These complications occur in a very small number of cases [2].

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 [2,3].
• 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.
• 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 [4].
• 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 [5-7].

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 information: Abortion (The Basics)
Patient information: Pregnancy in Rh-negative women (The Basics)
Patient information: 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 information: 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
Mifepristone for the medical termination of pregnancy
Misoprostol as a single agent for medical termination of pregnancy
Overview of pregnancy termination
Postpartum and postabortion contraception
Surgical termination of pregnancy: First trimester
Termination of pregnancy: Second trimester

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/abortion/default.asp)