Pregnancy Termination: Indications, Procedures and Challenges Michele K. Silverstein, MD, FACOG Thank you. I would like to take this opportunity thank you for the invitation to speak today. It is a privilege to participate in this conference

Overview Indications for Pregnancy Termination Methods/Choice of Procedure Complications As noted, the scope of my presentation will include these three categories

Abortion The termination of a pregnancy after, accompanied by, resulting in or closely followed by the death of an embryo or fetus. Spontaneous expulsion of a human fetus (i.e. miscarriage) The medical procedure of inducing expulsion of a human fetus to terminate a pregnancy. The definition of of abortion as noted in the Merriam Webster dictionary It is a word that often evokes a visceral response,even when used in clinical context and not a political debate

Induced abortion is one of the most commonly performed gynecologic procedures in the US <50% done at less than or equal to 8 weeks of gestation 90% done within the first twelve weeks of gestation 1% done after 20 weeks of gestation

Safety From a public health perspective, safe and legal abortion services are a cornerstone of maternal health care The risk of death from abortion at 16 weeks of gestation or less is 5-10 fold less than that of a continuing pregnancy Maternal mortality in the US is approximately 23 per 100,000 live births This safety of abortion is a very important consideration because there is a misconception that not intervening in certain situations poses less risk than an intervention.

Indications for Pregnancy Termination Elective Fetal Maternal Ectopic location of pregnancy This is a useful way to categorize the different indications for pregancy termination. I just want to touch on the first and last. Elective indication is purely that. An ectopic pregnancy is one in which implantation takes place outside of the endometrial cavity, most commonly the fallopian tube. It can be located in the ovary, abdomen or cervix, all of which are life threatening to the mother.

Fetal indications for pregnancy termination Fetal demise at any gestational age Diagnosis of genetic abnormality by chorionic villus sampling (CVS) or amniocentesis -chromosomal -inherited genetic disorders Structural abnormality detected on detailed anatomy ultrasound -i.e. cardiac malformations, anencephaly 3% of all live births affected by a major congenital anomaly Fetal demise is confirmed by ultrasound.

Fetal indications for pregnancy termination (2) Abnormal placentation -placenta previa, accreta, percreta -cesarean scar implantation Concerns for exposure to teratogens -radiation or other environmental concerns -medications There are only a few medications that are known teratogens. Teratogenic exposure accounts for 3-6% of all birth defects. (ACE Inhibitors, isotretinoin, ethanol, methotrexate,phenytoin, valgorate, warfarin)

Maternal Indications for Pregnancy Termination Medical Conditions Psychosocial Conditions Cases of rape or incest

Considerations of Maternal Disease and Pregnancy What is the impact of the disease on the pregnancy? What is the impact of pregnancy on the disease, both short and long term? What management would be recommended without pregnancy? Can the change in management be justified? What are the risks/benefits to the mother and fetus and are they aligned or contrary to each other? Advances in both medicine and surgical techniques have changed the playing field for many with underlying medical conditions. This underscores the need for both excellent pre-conceptual counselling and interdisciplinary collaboration to achieve the best outcomes. Despite this, serious medical or obstetrical conditions do arise that present critical issues for women and couples with an otherwise desired pregnancy. The physiologic changes of pregnancy are vast, and dynamic.

Maternal Medical Conditions Cardiovascular Disease Surgically Corrected Structural Heart Disease Chronic Hypertension Diabetes Malignancy Neurologic Psychiatric Surgery The most common indication for medical termination for maternal indication is cardiovascular disease. This includes congenital malformations that may have been repaired (Ebstein’s anomaly/valvular disease) or acquired diseases like cardiomyopathy

Psychosocial Factors Relationship Issues Other life stressors Financial Impact on the family

Other Indications Elective, no medical or other factors considered Ectopic pregnancy which requires surgery or other medical management

Options/Methods of Pregnancy Termination Choices are gestational age dependent Surgical Medical Expectant (in the cases of fetal demise)

Surgical Methods of Pregnancy Termination Transcervical Evacuation Dilatation and Curettage (D&C) Dilatation and Evacuation (D&E) Major Operations Hysterotomy Hysterectomy

Dilatation and Curettage Curettage by vacuum aspiration performed at gestational age of less than or equal to 12 weeks Technique of Menstrual Extraction can be used in the earliest of cases Use of a flexible cannula attached to an aspirator or syringe Manual Vacuum Aspiration (MVA) Generally does not require cervical dilation Electric Vacuum Extraction (EVA) more commonly performed Requires cervical dilation Use of either local or general anesthesia Greater than 6 weeks

Dilatation and Evacuation Term used for cervical dilatation followed by evacuation of the products of conception after 12 weeks Predominant method of termination beyond 12 weeks Requires a greater degree of cervical dilatation which necessitates the use of osmotic dilators for a period of 6-48 hours prior to the procedure Tents of Laminaria Japonica, a natural seaweed are the most commonly used dilators Use of special forceps to remove the larger volumes of tissue Prostaglandins may also be used for cervical ripening.

Major Operations Rarely Performed Hysterotomy - a surgical incision in the uterus by a transabdominal approach, in essence, a cesarean section Hysterectomy Most commonly performed with abnormal placentation or to complete a failed or complicated D&E

Non-surgical Options Medical Abortion Induction of Labor

Medical Abortion May be used up to 63 days of gestation, calculated by the LMP or 9 weeks gestational age by sonogram Most common regimen in the US is mifepristone 200 mg PO followed by buccal administration of 800 mcg of misoprostol 24-48 hours later Usually causes expulsion of the pregnancy within several hours of the misoprostol dose Up to 5% require surgical intervention Increased risk of Clostridial infection Misoprostol is taken in the privacy of one’s home

Induction of Labor Termination of Pregnancy by stimulation of labor like contractions that cause eventual expulsion of the fetus Instillation of hypertonic solution of saline or urea into the uterine cavity to cause contractions More commonly, prostaglandins and/or oxytocin are used Gestational age dependent Must be done in a hospital setting

Risks and Complications of Pregnancy Termination Immediate Delayed Late Both medical and surgical methods have risk of complications

Immediate Complications During or within 3 hours of procedure Uterine perforation (3-20/1000) Hemorrhage Cervical injury Anesthetic Complications Amniotic Fluid Embolism

Delayed Complications 3 hours to 28 days post-procedure Infection Hemorrhage Failed procedure, retained products of conception

Late Complications Asherman’s Syndrome- Intrauterine Adhesions Cervical Incompetence Psychological Effects Guilt Depression Anxiety

Abortion is never simple, no matter the state, the stage of pregnancy nor the reason.