1. Nov, 2015 INDUCED ABORTION Surgical and Medical Principles Context and Practice

2. 2 Keywords: Abortion, Medical abortion, RU-486, mifepristone, suction curettage OBJECTIVES  At the conclusion of the lecture on Abortion, the student will be able to:  Cite the worldwide prevalence of unsafe abortion, its morbidity, and mortality  Explain the term surgical abortion and identify techniques of pregnancy termination  Explain the term medical abortion and describe the mechanism of action of the drugs used to induce abortion  Describe the difference between emergency contraception and medical abortion

3. 3 Finer & Henshaw, 2006 (2002 data) UNINTENDED PREGNANCY IN US—2008

4. 4 Outcomes of Unintended Pregnancies, 2006 Finer & Zolna, 2011. Contraception 84:476 National data from NSFG, National suvery of abortion patients, NSHC, US Census Bureau

5. 5 Disparities in Unintended Pregnancy  Overall unintended pregnancy rates are up slightly,, but...  Unintended pregnancy has increased among poor women, while decreasing among higher income women  Rate of unintended pregnancy among poor women was >5X than that of women with high income

6. 6 Disparities in Unintended Pregnancy Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001-2008. Am J Public Health. 2014;104 Suppl 1:S43-48.

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8. Abortion Terminology Induced Abortion--removal of fetus or embryo from the uterus prior to viability “ Therapeutic ”, “ Elective ”, “ Late term ”, “ Partial-birth Ab ” Spontaneous Abortion = “ Miscarriage ” Threatened Ab--Vaginal bleeding in 1st 20 wks, cervical os closed Incomplete Ab--POCs retained; often with excess bleeding Inevitable Ab--Ab will occur; Os is open Missed Ab--Retained pregnancy tissue, not expelled Septic Ab--Incomplete Ab with sepsis Abortion jabberwocky: the need for better terminologyAbortion jabberwocky: the need for better terminology. By David A. Grimes and Gretchen Stuart. Contraception Volume 81, Issue 2, Pages 93-96 (February 2010)

9. 9 Incidence of Abortion  In 2011, ~730,322 pregnancies were terminated by abortion in the US  Abortion rate 13.9 abortions/1000 women aged 15/44  Abortion ratio 219 abortions/1000 live births  Abortion rate decreased 5% compared with 2010  Women in their 20s accounted for the majority of abortions  Abortion ratios were highest among adolescents  CDC.gov Abortion Surveillance—United States, 2011

10. Abortion Surveillance--US, 2011  ~730,000 abortions reported to CDC in 2008  Abortion rate 13.9/1,000 women 15-44 (no change)  Abortion ratio 219 abortions/1,000 live births  Declines in Ab #, rates, ratios since 2002 Pazol et al. Abortion Surveillance--United States, 2011. MMWR. Nov 28, 2014/63(SS11) 1-41.

11. Abortion Surveillance--US, 2011  Women 20-29 yo accounted for 57.8% of ABs, with highest abortion rates (Abs/1000 women 15-44)  Abortion ratios highest in teens (Abs/1000 live births) Pazol et al. Abortion Surveillance--United States, 2011. MMWR. Nov 28, 2014/63(SS11) 1-41.

12. Gestational Age at time of Abortion US, 2011 Pazol et al. Abortion Surveillance--United States, 2011. MMWR. Nov 28, 2014/63(SS11) 1-41.

13. Abortions by Gestational Age (From LMP) 2011 Pazol et al. Abortion Surveillance--United States, 2011. MMWR. Nov 28, 2014/63(SS11) 1-41.

14. 14 Incidence of Abortion  Almost 2% of all women aged 15-44 had an abortion in 2005  Abortion is one of the most common surgical procedures in the US  ~half of American women have experienced an unintended pregnancy by age 45  At 2008 rates, 1/10 women will have an abortion by age 20; ¼ by age 30, and 3/10 American women will have had an abortion by age 45. Jones, R.K., et al., Abortion in the United States: incidence and access to services, 2005. Perspect Sex Reprod Health, 2008. 40(1): p. 6-16. AGI, Induced Abortion in the United States, July 2014 Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstetrics and gynecology. Jun 2011;117(6):1358-1366

15. 15 Incidence of early medication abortion, 2011  Early medication abortion accounted for 19.1% of all abortions, an increase of 3% from 2010-2011.  From 2002 to 2011, medication abortions have increased ~20%  An estimated 28.5% of eligible abortions (those performed up to 9 weeks) were early medication abortions.  57% of all known providers offered this service in 2005, compared to 33% in early 2001. CDC Abortion Surveillance 2011

16. Abortion Surveillance--US, 2009  64.5% of abortions performed at <=8 weeks;  91.4% ≤ weeks  36% ≤ 6weeks  Few abortions 14-20 weeks—7.3% or >=21 weeks 1.4%  Curettage = 71% <=13 wks; Medication Ab 18.3% Pazol et al. Abortion Surveillance--United States, 2011. MMWR. Nov 28, 2014/63(SS11) 1-41..

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19. SAFETY OF ABORTION  A 1 ST trimeter abortion is one of the safest medical procedures, with less than 0.05% risk of major complications requiring hospitalization  Vacuum abortion—virtually no long risk risks of infertility, ectopic pregnancy, subsequent miscarriage, or congenital malformation (need to control for factors such as STI’s)  No significant difference between medication abortion, surgical abortion, or no abortion in risk of preterm or LBW delivery  Exhaustive reviews by US and UK gov panels have consistently found no association between abortion and breast cancer.  Well-designed studies show no causal relationship between abortion and mental health problems (must control for history of psychiatric illness) 19 Fact Sheet, July 2014, Guttmacher Institute Boonstra, Abortion in Women’s Lives, Guttmacher.org

20. WHO HAS ABORTIONS IN THE U.S.? 20

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22. 22 VACUUM (Surgical) ABORTION  Involves instrumentation of uterus with suction cannula or sharp curette  uses vacuum (suction) to remove pregnancy from uterus  Can be provided as early as 5 weeks from LMP  Can be provided in office facility, procedure room, surgicenter or OR

23. 23 Surgical Abortion: Characteristics  Safe and highly effective (>99%)  Short time to completion  Few required visits  Short duration of bleeding  No exposure to possible teratogens  Can be performed later in gestation

24. 24 Surgical Abortion: Safety  Abortion mortality rate: <1:100,000 procedures  Maternal Mortality rate: ~10:100,000 live births  Complications  Infection: <2% of procedures  Incomplete abortion: ~0.5-3% of procedures  Hemorrhage (requiring transfusion): ~1/1000  Perforation: ~1/1000

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26. 26 Abortion Technique

27. 27 Abortion Technique

28. 28 Abortion Technique

29. 29 Medication (Medical) Abortion Agents  1970s Misoprostol (Prostaglandin analogue)  1980s Mifepristone = RU486 (anti-Progesterone)  1990s Methotrexate (anti-Metabolite)  Combination Regimens  Mifepristone + Misoprostol  Methotrexate + Misoprostol

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31. 31 Medication (Medical) Abortion--Benefits  Safe and effective  No need for gestational delay  Avoids surgical and anesthetic risk  Psychological advantages  Increases method choices for women

32. 32 Alone: Efficacy--50-85% Dramatically declines with increasing GA Abortion time unpredictable Alone: Efficacy--50-85% Dramatically declines with increasing GA Abortion time unpredictable Mifepristone With Misoprostol: Efficacy--92-99% Maintained until 7-9 weeks GA Majority of abortions occur within 4 h after PG administration unpredictable With Misoprostol: Efficacy--92-99% Maintained until 7-9 weeks GA Majority of abortions occur within 4 h after PG administration unpredictable

33. 33 Grimes, 1997 Mifepristone + Various PG Analogues  Mean Efficacy 95%  Adverse Events:  Transfusion 0.1%  Pain treated with Narcotics 4-15%  Vomiting 12-44%  Diarrhea 7-39%

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36. 36 Medication Abortions  From pregnancy diagnosis through week 7, medical AND surgical abortion techniques are both safe, effective, and well-accepted.  A diverse group of clinicians can be trained to offer medical abortion provided backup access to surgical abortion is available.

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39. Abortion--Take-Home Points  In the US and worldwide, 30-50+% of pregnancies are unintended  Poor, young women and minorities are more likely to have unintended pregnancies  Most abortions in the US are at an early GA  Abortion in the US is legal and safe  Unsafe abortions are a major cause of maternal deaths worldwide

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